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WHTM 01-05 Audit ToolWHTM Form 2

Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these.

Other questions and statements relate to continuously improving practice. These are highlighted in yellow.The relevant chapter or paragraph number of WHTM 01-05 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 compliant

NOT fully compliant

Evidence

1 The practice has a nominated lead *responsible for infection control and decontamination (Ch 1 and 9)

Yes Miles Gladson is responsible for infection control and decontamination.

2 The practice has an identified individual with responsibility and authority to ensure that all staff comply with medical device procedures.(Ch 9)

Yes The identified individual that is responsible is Miles Gladson.

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

Yes The infection control policy is kept behind reception in the policy file.

Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to continuously improving practice. These are highlighted in yellow.

Dental Postgraduate Department Wales Deanery 8th Floor Neuadd Meirionnydd Heath Park Cardiff CF14 4YS T +44 (0) 29 20687830 www.walesdeanery.org/dentistry Version 5: 05/03/14 1

and single-use instruments? (An infection control policy) (Ch 1)

NUMBER STATEMENT/QUESTION Fully compliant NOT fully compliant Evidence Notes

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)

Yes Included in the infection control policy. All instruments are

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)

Yes Kept in policy file under inoculation injuries policy. Also procedures for sharps incidents are displayed in both surgeries.

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)

Yes Kept under infection control policy. Protocol in place in surgeries. All injuries reported to Miles or Sarah.

7 Does the practice have a policy and Yes Canon is used for There is a separate file Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to continuously improving practice. These are highlighted in yellow.


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)

disposal of waste.PPE, hand hygiene, spillages and cleaning are kept in the policy file.

kept for waste, COSHH and a file kept for cleaning and maintaining the environment.

All


NOT fully compliant

Evidence Notes

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)

No Not used in practice.

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)

Yes Safe use of water is in the policy file. The practice has undertaken a risk assessment for Legionella.



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)

Yes Only steriliser is used in practice. A log book is available, kept in decontamination room. File is kept that includes maintenance and repair records.

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)

Yes Log book available for steriliser which includes test results for WHTM test schedules.

*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.

Section B. APPLICATION OF POLICIESB(i) SINGLE USE EQUIPMENT


NOT fully compliant

Evidence Notes

12 Single-use instruments are never reprocessed (para 2.17 to 2.19)

Fully comply.

List of single-use instruments are kept in policy file.

Click here to enter text.

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)

Yes Instruments listed are identified as single-use in policy file.


14 Endodontic files and reamers are never reused (para Yes Listed as single-use in Click here to enter text.Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to continuously improving practice. These are highlighted in yellow.


2.21) policy file.

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

Fully comply.

Assembled according to instructions on side of sharps container.

17 Sharps containers are available at the point of use and positioned safely

Fully comply.

Sharps containers are positioned safely in both surgeries.

NUMBER STATEMENT/QUESTION Fully compliant NOT fully compliant Evidence Notes

18 In-use sharps containers are labelled with date, location and a signature

Fully comply. All sharps containers are labelled with date, location and signed.

19 Needles are never re-sheathed except with the use of an approved re-sheathing device.

Yes Re-sheathing device is used by both dentists, this is the only way needles are re-sheathed.

20 Are disposable needles and disposable syringes discarded as a single unit?

Yes . Disposable syringes not frequently used in practice



21 Sharps containers are never filled beyond the indicator mark

Fully comply. Never filled beyond three quarters full.

22 Are sharps containers locked with the integral lock when filled to the indicator mark?

Yes All sharps containers locked with integral lock once filled three quarters of the way.

23 Full sharps containers are stored in a secure facility away from public access

Fully comply. All stored in areas that only staff have access to.

24 The use of safety syringes and other sharps safety devices, as appropriate to clinical practice (e.g. safety IV canulas) has been considered.

Yes Sharps safety devices are used. Others listed have been considered.

25 Do all staff know what to do in the event of a sharps injury?

Yes Follow protocol displayed in surgery and report to Miles or Sarah.

26 All sharps injuries are recorded in accident book. (para 2.6)

Yes All injuries are recorded in the accident book kept behind recpetion.

NUMBER STATEMENT/QUESTION Fully compliant NOT fully compliant

Evidence Notes

B (iii) INSTRUMENT CLEANING

27 All new reusable instruments are decontaminated prior to use (para 3.4)

Yes All instruments decontaminated then bagged before use.



28 Instrument trays are appropriately decontaminated prior to use (para 2.14)

Fully comply. Instruments are always appropriately decontaminated before use.

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)

Yes Any instruments left on trays at the end of each session are immersed in water with instrument disinfectant before being taken to be cleaned and sterlised.

30 Instruments are cleaned prior to disinfection and sterilisation in line with manufacturer’s instructions.(Ch 3.0)

Yes All instruments cleaned according to manufacturers instructions. They are immersed in water before disinfection and sterilisation.

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)

Yes All instruments are immersed in water before being cleaned manually, once cleaned manually then sterilised.

32 There is a separate dedicated sink for handwashing in each room where decontamination of equipment takes place (para 2.4r)

Yes Decontamination room has two sinks and there is a separate dedicated sink for hand washing only.




Evidence Notes

B (iv) DECONTAMINATION ENVIRONMENT

33 In the practice, are there

dedicated decontamination areas?

ORdedicated decontamination room(s)?

Fully comply. There is a dedicated decontamination room.

34 If you have separate, dedicated decontamination room/s are they used only for decontamination duties? (para 1.9)

No The decontamination room is also used for stock, the segregation is well defined from decontamination and stock.

35 Is the decontamination environment segregated from the clinical activity? (para 1.9, 5.1)

Yes No clinical activity takes place in decontamination room.

36 Are decontamination areas and work surfaces clean and uncluttered? (para 4.29)

Yes All surfaces are kept clean and uncluttered.

37 Is there a clear workflow from dirty to clean activity?(chapter 5)

Yes The workflow is clear from dirty to clean activity.

This is from the surgery to decontamination room.

38 There is adequate ventilation to serve the area containing

Yes The area containing decontamination equipment



decontamination equipment (para 6.41 and 6.42)

is well ventilated at all times.

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

Yes The decontamination area is always well ventilated, removing any fumes including from chemicals used in cleaning and decontamination.


Evidence Notes

40 There are no portable fans used in clinical/decontamination areas (in line with good infection control) (para 6.41)

Yes No fans are used in clinical/decontamination areas.

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)

Yes Air is ventilated directly to oustide

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)

Yes The decontamination area has two separate sinks for cleaning and rinsing contaminated instruments.



ORThe 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)

Fully comply Heavy duty gloves are used for manual cleaning of instruments.

44 Instruments are fully immersed during cleaning, in line with manufacturer’s advice (para 16.3c)

Yes Instruments are fully immersed in water during cleaning according to manufacturers advice.


Evidence Notes

45 The temperature of water for manual cleaning is monitored to 45°C or lower (para 16.3b)

Fully comply The temperature of the water is monitored when cleaning instruments. The temperature is never above 45°C.

The temperature of the water is recorded each time instruments are manually cleaned.

46 Detergents used are specifically formulated for the cleaning of re-usable dental instruments ( para 16.3)

Yes Instrument disinfectant is used for manually cleaning reusable instruments.

47 Detergents used for manual cleaning are designed for the manual cleaning of dental instruments.(para 16.3a)

Yes Detergents used are specifically used for manual cleaning of dental instruments only.



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)

Yes Brushes used are washed after each use. Replaced when damaged. Brushes used for burs are suitable for sterilisation.

49 Instruments that are not decontaminated immediately are kept moist until they are decontaminated (paras 2.15 and 3.5)

Fully comply. Before instruments are cleaned and sterilised they are immersed in water.

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)

Not used in practice.

51 Hinged or jointed instruments are opened prior to placing them in the instruments basket or cassette (3.30)



Evidence Notes

52 Is the lid of the ultrasonic cleaner closed during cleaning cycles and whilst not in use to prevent

Not used in pracitce.



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).


Evidence Notes

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 maintainedcorrectly 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 01.05 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)

Yes Instruments are inspected before and after sterilisation.

If found not to be clean, instruments are cleaned and sterilised again.


Evidence Notes

C (v)STERILIZATION

65 Instruments that are not clean are returned to the cleaning cycle (para 3.52)

Yes Instruments that are not cleaned will begin cleaning cycle again.

66 Instruments sterilized in a non-vacuum (type N) steriliser are dried appropriately prior to packing using disposable non-linting cloth (para 2.4j)

Yes All instruments are dried before packing.

67 All instruments sterilised in a non- vacuum (type N) bench top sterilizer

Yes All instruments are unwrapped before




are unwrapped prior to sterilization (para 4.24b)

sterilisation at all times.

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)

Type N used.

69 Packs are inspected to ensure there is no visible moisture present in the packs prior to storage (para 1.25)

Fully comply. Instruments are dried before packing, inspected after packing to ensure no visible moisture, then stored away.

70 Are all instruments compatible with the configured sterilization cycle (time and temperature), and the manufacturers instructions? (para 10.23)

Yes All instruments used in surgery are suitable for sterilisation cycle, time and temperature.

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)

Fully comply. The steriliser is correctly loaded according to the operating manual. This is to avoid overloading the steriliser.


Evidence Notes

72 Freshly distilled water, sterile water for irrigation or reverse osmosis (RO) water are used to generate

Fully comply. Freshly distilled water is used to generate steam in the steriliser.



steam in the steriliser (para 4.13)

73 Are all stored sterilized instruments packaged and dated with the date of sterilisation? (para 4.26)

Yes All instruments are packed and dated for a year after sterilisation.

74 The autoclave reservoir is drained and left clean and dry at the end of each day. (para 4.13)

Yes The autoclave is drained at the end of every day.

75 Are opened bottles of sterile or distilled water discarded at the end of each working day? (para 17.6)

No Distilled water is stored in the refrigerator. Distilled water is discarded of after 36 hours.

76 A record is made of daily checks including date, temperature and pressure achieved and satisfactory completion for each cycle (para 4.18)

Yes Date, temperature and pressure achieved is recorded every day. The records are kept in a logbook in decontamination room.

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)

Yes Documentation is kept in autoclave file for annual testing, maintenance records and service reports, behind reception.

Documentation to provide daily and weekly testing is stored in the decontamination room.

78 Is there a maintenance contract in place to ensure the sterilizer is serviced in line with manufacturer’s schedule? (para 12.1)

Yes Maintenance contract to ensure the steriliser is serviced is with Eschman.



79 Are there systems in place to check that that the maintenance contract is properly met ? Ref: Service level agreement

Yes The steriliser is serviced annually.


Evidence Notes

80 Is there a contract in place to ensure the sterilizer is validated in line with WHTM 01/05? (para 12.2)

Yes Contract in place with Eschman.

Documents for the steriliser are found in the steriliser file behind reception.

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)

Yes System in place with Eschman.

82 Are procedures in place to remove Sterilizers from service that fail to meet testing requirements until the fault is rectified (para 4.23)

Yes Sterilisers that fail to meet testing requirements

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)

Yes The steriliser has a printer which is used to log data, the data is manually logged daily. Logbook stored in decontamination room.

C (vi) HANDPIECES



84 Handpieces are decontaminated between each patient in accordance with manufacturers’ instructions (para 2.4q)

Yes Hand pieces are decontaminated according to manufacturers instructions.


85 Handpieces that are manually cleaned/disinfected are lubricated with oil before steam sterilization in accordance with manufacturers’ instructions (para 3.55)

Yes Hand pieces are manually cleaned with alcohol wipes and lubricated with oil before sterilisation.

86 Handpieces washed by a specific handpiece cleaning device are lubricated with oil before sterilization in accordance with manufacturers’ instructions (para 2.4q, Ch3 note 2)

Not used in pracitce. Hand pieces manually cleaned.


Evidence Notes

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)

Washer disinfector not used in practice.

88 Are separate canisters of lubricant used for unclean, cleaned and sterilised handpieces / instruments?

Yes Separate canisters of lubricant for unclean and cleaned instruments are



(para 3.56) clearly segregated into dirty and clean areas.

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)

Yes Disinfectant solutions are changed daily in line with manufacturers guidelines.

91 Reusable trays are decontaminated and sterilized after every use OR the practice uses disposable instrument trays (para 2.17, 2.18)

Yes Instrument trays are decontaminated after every use. The practice also uses tray paper with reusable trays.

92 Are film holders used in intra-oral radiography subject to decontamination after every patient use in accordance with manufacturers’ instructions? (para 6.72)

Yes Film holders are decontaminated and sterilised after every use.

NUMBER STATEMENT/QUESTION Fully compliant NOT fully Evidence Notes



compliantC (viii) SEDATION EQUIPMENT

93 Are ISM flowmeters used and maintained in accordance with original equipment manufacturers’ or suppliers’ instructions?

Not used in pracitce.

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)

Fully comply. Cleaning equipment is not stored in clinical areas.

96 Are chlorine-releasing agents available for blood/bodilyfluid spillages and used as per manufacturers’ instructions? (para 6.74)

Yes Stored in decontamination room, and used according to manufacturers instructions.

Section D STORAGE AND MOVEMENT OF INSTRUMENTS / MEDICAL DEVICES / OTHER DEVICES D (i) STORAGE

97 Instruments are stored in a Yes Instruments have a Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to continuously improving practice. These are highlighted in yellow.


dedicated, secure, dry and cool environment (para 4.27 to 4.31)

dedicated, secure, dry and cool environment.


Evidence Notes

98 Does the practice have a system in place to recordreprocessing dates and storage time for wrapped instruments? (para 2.4k)

No This could be improved for future audits by having a system to check instrument dates weekly/monthly.

99 Instruments wrapped and packed after processing in a type N sterilizer are stored for no more than 1 year (para 2.4k)

Fully comply. Instruments begin sterilisation cycle again if they have not been used for a year.

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)

Type N steriliser used.

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)

Yes Wrapped instruments are stored in cupboards in surgeries, away from the clinical environment. They are used in a strict rotation, and not used after the date on sterilised packs.



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)

Yes Instruments must be in containers that are leak proof, rigid and close securely.


Evidence Notes

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 2.26 – 2.32)

Yes The same procedure applies as transporting instruments within the practice, and in addition a record is made of the date of the visit, the vehicle used and the dental instruments used.

105 There is a clear policy in place for Yes Policy kept in policy file. Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to continuously improving practice. These are highlighted in yellow.


transport of instruments in and out of the practice (para 2.26 and 2.30)

Moving instruments to and from separate decontamination areas.

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)

Yes All impressions are decontaminated prior to despatch to the laboratory, in line with the manufacturers instructions and postal regulations.

107 Instruments sent for repair are labelled to identify that they have been through the decontamination process (para 3.54)

Yes Instruments sent for repair are labelled with a green sticker that identifies they have been decontaminated.

108 Contaminated medical devices are decontaminated prior to inspection, maintenance or repair (para 3.54)

Yes Contaminated medical devices are always decontaminated before any inspection, maintenance or repair.

109 If transport containers are in use, are they lidded, clean, leakproof and in good working order? (para 2.27)

Yes Moving instruments to and from separate decontamination areas, policy states that transport containers must be leak proof and close securely.

All containers are in good working order.


Evidence Notes



110 Are transport containers cleaned, disinfected and dried following each use? (para 2.28)

Yes Cleaned and disinfected after every use with fresh detergent solution.

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) cleaning duties?

iii) the prevention and management of blood-borne virus exposure?

Yes Staff training is received as part of staff induction programme. The induction programme is found in the policy file, under the staff section. The policy file is kept behind reception.

112 Are staff trained in the use of personal protective equipment as part of the practice induction? (para 6.14)

Yes Use of Personal Protective Equipment policy.

113 Have all staff attended induction and Yes Incorporated at the start of



ongoing training in the process of waste segregation and disposal? (Appendix 1)

induction program.

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)

Yes Training received as part of induction program.


Evidence Notes

115 A record of all staff training is maintained.(para 1.26)

Yes All staff training is kept in individual files for each staff member.

116 Can decontamination and clinical staff provide documentary evidence of previous successful immunisation with hepatitis B vaccine? (para 2.4p)

Yes All immunisation records with hepatitis B vaccine are stored in immunisation file. Stored behind reception.

117 All inoculation injuries are documented and records maintained. (Ref -PHW. All-Wales Inoculation Injury Guidelines for Primary Care)

Yes All inoculation injuries are recorded in accident book kept behind reception.

Section F. QUALITY ASSURANCE F (i) HAND WASHING

118 Are hand hygiene facilities clean and intact (check sinks taps, splash-

Yes All hand hygiene facilities are clean and intact



backs, liquid soap and paper-towel dispensers)? (Ref Public Health Wales Standard Infection Precautions Policy)

including sink taps, splash-backs, liquid soap and paper-towel dispensers.

119 Are wash-hand basins free from equipment and other utility items? (Ref Public Health Wales Standard Infection Precautions)

Yes All hand basins are free from equipment and other utility items.

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)

Yes All are lever operated, patient toilet taps are sensor operated.


Evidence Notes

121 Are thermostatically controlled taps in use?

No Taps are standard mixers

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)

Yes Sink has plug and overflow.

123 Good quality liquid soap is available at each wash-hand basin (para 6.12)

Yes Anti-bacterial liquid soap is available at each wash-hand basin.

Used in surgeries and in patient toilet.

124 The soap cartridges within the dispensers are single use and are

Yes These are never refilled.



never refilled. (para 6.12)

125 Bar soap is not used at wash-hand basins (para 6.6)

Fully comply. Bar soap is not used at any wash-hand basins.

126 Reusable nail brushes are not present at wash-hand basins (para 6.9 and Appendix 2)

Fully Comply. Nail brushes are not used.

127 Are disposable absorbent paper towels or hand dryers available at all wash-hand basins? (para 6.7)

Yes Absorbent paper towels and hand dryers are available at wash hand basins.

128 Are hand-cream dispensers with disposable cartridges available for all clinical and decontamination staff? (para 6.8)

Yes Hand cream dispensers with disposable cartridges are available for all clinical staff and decontamination staff in all surgeries and the decontamination room.

129 Skin disinfectant e.g. alcohol gel is available for hand hygiene (Ref The Public Health Wales Standard Infection Precautions Policy and Appendix 2)

Fully compliant Skin disinfectant throughout the practice for staff and patients.

Used in surgeries and in waiting rooms.


Evidence Notes

130 Is there a separate dedicated hand basin provided for hand hygiene in each surgery where clinical practice takes place? (para 6.11)

Yes There are two sinks in both surgeries. In both surgeries there is a dedicated hand basin.



131 Laminated or wipe-clean posters promoting hand hygiene are on display (para 6.13)

Fully comply. The posters are displayed at the dedicated hand basin in the surgery.

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)

Fully comply. All clinical and decontamination staff always remove any wrist jewellery, watches and rings with stones during clinical and decontamination procedures. Disposable forearm covers are not use, clinical and decontamination staff are bare below elbows.

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)

Fully comply. All clinical staff are compliant, no nail varnish or nail extensions are worn. Nails are short and clean.

134 Is hand hygiene performed before

i) donning and after the removal of gloves? (para 6.5)

Yes Hand hygiene is performed using alcohol gel and anti bacterial hand wash. There is a limited amount of times alcohol gel should be used. When possible anti bacterial hand wash should be used.

Alcohol gel is effective hand hygiene but should not replace the use of anti bacterial hand wash. Alcohol gel should be used when anti bacterial hand wash is not available.



ii) before and after every new patient contact? (para 6.5)


Evidence Notes

135 Is hand hygiene an integral part of staff induction? (para 6.3)

Yes Found in policy file in practice team section.

136 Is hand hygiene training provided periodically throughout the year? (para 6.3)

Yes Hand hygiene is provided annually.

137 Hand hygiene training records are maintained (para 6.3 and 1.26)

Not fully compliant.

Hand hygiene records are not maintained.

To improve for the future, we will aim to have hand hygiene training records.

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?

Fully comply. All listed are always used where there is a danger of splatter or aerosol formation. List of PPE is found in the policy file.

Used by clinical staff.

139 Eye protection provided for patients and staff is decontaminated after each episode of patient care

Fully comply. Eye protection is always provided for patients and staff. Both are

Eye protection is decontaminated using alcohol wipes or



decontaminated after each episode of patient care.

disinfectant spray.

140 Eye protection for staff used during decontamination procedures is cleaned after each session or sooner if visibly decontaminated

Yes Eye protection for staff is used during decontamination procedures after each session.

Eye protection for staff is replaced is visibly decontaminated.

141 Items of PPE are stored in accordance with manufacturers’ instructions

Yes All stored according to manufacturers instructions.


Evidence Notes

142 Masks are disposed of as clinical waste after each use

Yes Disposed of into clinical waste after each use.

143 Single-use plastic aprons are disposed of as clinical waste

Yes Disposed of as clinical waste.

144 All single-use PPE items are disposed of after each episode of patient care

Yes Disposed of after each episode of patient care, or replaced sooner if needed.

145 Alternatives to latex gloves are available

Latex gloves are not used in practice. Only nitrile gloves are available.

146 Powder-free CE-marked gloves are Fully comply. All gloves used are powder-Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to continuously improving practice. These are highlighted in yellow.


used routinely free.

147 Surgery wear worn by all staff is changed at the end of each day or when visibly contaminated

Yes. Changed at the end of the day.

148 Disposable plastic aprons are worn during all decontamination processes or clinical procedures where there is a risk that clothing/uniform may become contaminated

Yes When there is a risk of uniform becoming contaminated disposable plastic aprons are worn.

Disposable plastic aprons are disposed of after decontamination processes or clinical procedures.


Evidence Notes

149 Are clean, heavy-duty domestic gloves

i) available in a range of sizes?

ii) Used for domestic cleaning and decontamination procedures where necessary?

Yes – Available in all sizes.

– Used only for domestic cleaning and decontamination procedures.

– Replaced when damaged.

– Washed with detergent and hot water, left to dry



iii) replaced weekly or moreYEs frequently if torn?

iv) washed with detergent and hot water and left to dry after each use?

(ref Appendix 2)

after each use.

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)

Yes The clinical and decontamination environment is tidy and uncluttered and safe for staff to work in.

151 Do all floor coverings in clinical and decontamination areas have coved edges that are sealed and impervious to moisture? (para 6.46)

Yes All decontamination and clinical areas have coved edges that are sealed and impervious to moisture.

152 Are floor coverings in clinical and decontamination areas impervious and easy-to-clean?(para 6.47)

Yes Yes all areas are impervious and easy to clean.




Evidence Notes

153 Floors, cupboard doors and accessible high-level surfaces are cleaned daily (para 6.63)

Fully comply All are cleaned daily.

154 Rooms where clinical procedures take place are not carpeted (para 6.46)

Fully comply No rooms where clinical procedures take place are not carpeted.

155 Are keyboard covers or “easy-clean” waterproof keyboards used in clinical areas? (para 6.66)

Fully comply All keyboards have easy clean covers on them in all clinical areas.

156 Are all surfaces in clinical and decontamination areas impervious and easy to clean? (para 6.46)

Yes All surfaces in clinical areas are impervious and easy to clean.

157 Are the surfaces of accessible ventilation fittings/grills cleaned weekly? (para 6.64)

Yes Accessible fittings are cleaned.

158 Are all surfaces (i.e. walls, floors, ceilings, fixtures and fittings, and chairs) free from dust and visible dirt?(para 6.63)

Yes All surfaces are cleaned weekly, or before if dirt and dust is visible.

Cleaning file is used and ticked when cleaning has been done. File is kept behind reception.

159 Are all work-surface joints intact and seamless with no visible damage? (para 6.46)

Fully comply All work surface joints are intact and seamless with no visible damage.



160 Are all surfaces (i.e. walls, floors, ceilings, fixtures and fittings, and chairs) free from damage and abrasion? (para 6.39)

Yes All surfaces are free from damage and abrasion.


Evidence Notes

F (iv) DECONTAMINATION OF CLINICAL AREAS

161 Soft toys are not available (para 6.73)

Fully comply. There are no soft toys available.

162 The dental chair is free from rips or tears (para 6.62)

Fully comply. Both dental chairs are free from rips and tears.

163 The dental chair is cleaned between each patient (para 6.62)

Yes The dental chair is cleaned between each patient and at the end of the day.

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)

Yes All listed are cleaned between each patient.

165 Are all taps, drainage points, Yes All listed are cleaned after Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to continuously improving practice. These are highlighted in yellow.


splashbacks, sinks, aspirators, drains and spittoons cleaned after every session with a surfactant/detergent? (para 6.63)

every session with a surfactant/detergent.

F (v) WATER SYSTEMS (Paras 6.80 to 6.91 and Ch 19)

166 Are dental unit waterlines and handpieces fitted with anti-retraction valves as appropriate?

Yes Waterlines and hand pieces are fitted with anti-retraction valves.

167 Where bottled water systems are not used, is there a physical air gap separating DUWLs from mains water systems (Type A)?

Bottle water throughout


Evidence Notes

168 Are dental unit waterlines flushed for 2 minutes at the start of each working day and for 20–30 seconds between every patient?

No Waterlines are not flushed at the start of each working day because the water is chemically treated with alpron.

Water quality is monitored through ‘dipslides’

169 Are dental unit waterlines treated with an appropriate biocide according to manufacturer’s instructions?

Yes

170 Are self-contained water bottles (bottled water system) removed, flushed with distilled or clean RO

Not fully compliant.

The water used is treated with alpron.

Alpron manufacturers advocate bottles



water and left open to the air for drying on a daily basis and if necessary overnight, and in accordance with manufacturers’ guidance?

are not removed and water lines purged

171 For dental surgical procedures involving irrigation, is a separate single-use sterile water source used for irrigation?

Surgical extractions not done here

172 Is an independent bottled-water system used to dispense fresh distilled, reverse osmosis (RO) or sterile water to supply the DUWL?

yes Distiller used to provide fresh water daily

173 Are in-line filters cleaned /replaced as per manufacturer’s instructions?

Yes Replaced/cleaned according to manufacturers instructions.

174 Does the practice have a written scheme for prevention of legionella contamination in water pipes and other water lines? (para 19.2)

Yes Prevention of legionella contamination in water pipes and other water lines can be found in the policy file.


Evidence Notes

F (vi) WASTE DISPOSAL (Appendix 1)

175 The Registered Manager (or nominated other) is identified as

Yes Miles Gladson is identified as being the lead person for



being the lead person for waste disposal

waste disposal.

176 The Registered Manager is aware of the Hazardous Waste (England and Wales) Regulations and ensures the practice complies with them.

Yes The practice is fully compliant with the Hazardous Waste Regulations.

177 The Registered Manager (or nominated other) ensures that waste is:-

i. Correctly segregated

ii. Stored safely and securely away from areas of public access

iii. Packaged appropriately to be transported

iv. 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

Fully comply. All waste is correctly segregated, stored safely and securely, only staff have access to these areas. Waste is packed appropriately to be transported.

All waste is described accurately on the accompanying documents when removed from the premises.

The waste is transferred to an authorised person for transport to an authorised waste site. Waste is taken by waste disposal company Canon.

Necessary records and returns are kept in the practice in the Hazardous waste file.

The Hazardous Waste file is kept behind reception.



necessary records and returns kept in the practice. (“Records and 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

N/A

179 Staff working on mobile dental units have been trained in MDU decontamination and disinfection procedures

N/A

180 All MDU waste is disposed of according to HB policies

N/A

181 MDUs are cleaned externally and internally in line with HB timetable

N/A

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 07-01 Safe Management of Health Care Waste

