Dental Audit Report

Infection Control Audit Report Date audited:

10/06/2016

Location:

Gordon House 1-6 Station Road Mill Hill London NW7 2JU

Client name:

Demonstration

Auditor:

Kevin Malambo

Accompanied by:

Jennifer

Additional info:

% Compliance

e

Section Governance & Documentary Evidence

100 %

Staff Records

100 %

50 %

Clinical Environment Clinical Practice

pl

Expertise

100 % 100 %

Clinical Equipment Dental Equipment

100 % 91 %

100 %

m

Hand Hygiene

100 %

Waste Management

100 %

Dental Decontamination Room

100 %

Dental Instrument - Decontamination Practices

100 %

Ultrasonic Cleaner - Validation and Maintenance

100 %

Ultrasonic Cleaner - Practices

100 %

Automated Washer/Disinfector - Validation and Maintenance.

100 %

Automated Washer/Disinfector - Practices

100 %

Steriliser - Validation and Maintenance

100 %

Steriliser - Practices

100 %

Sa

Sharps Management

Dental Instrument - Packaging and Storage

67 %

Transport of Dental Instruments - Dirty

100 %

Transport of Dental Instruments - Reprocessed

100 %

Transportation of Dental Instruments - Off-site

100 %

Total

96 %

Corrective actions:

Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Dental HTM 01-05 (AT007)

Date Approved: 10/06/2016

ICAT Audit Tool Vrs 2.0 Page 1 of 22

Expertise There should be a designated named person as the decontamination lead of re-usable dental instruments/clinical equipment/medical devices.

There should be a designated named person as the environmental cleaning lead Staff should be aware of how to contact Occupational Health for services and advice.

Dental Equipment Re-usable tungsten carbide or diamond burrs should be decontaminated using an enzymatic solution or via an AWD after a single use.

Re-usable aspirator tips should be decontaminated either by manually cleaning or using an USC/AWD after each use.

Dental Instrument - Packaging and Storage

e

Only packaging bearing the appropriate standard BS or CE symbols should be used.

Pre-wrapped dental instruments should be sterilised in a vacuum steriliser only.

Demonstration 1 Gordon House

pl

An aseptic technique should be used to wrap dental instruments after sterilisation.

Governance & Documentary Evidence

Question

m

Governance documents should be accessible to staff and available for inspection

Compliance

Comments

Rationale

Compliant

An up-to-date copy of HTM 01-05 Decontamination in Primary Care Dental Practices DH 2013 is available for staff to refer to.

Compliant

Expert Guidance

A risk assessment, audits and action plans are in place that outlines the practices intention to achieve compliance with the Best Practice status as part of the Essential Quality Requirements in HTM 01-05 Decontamination in primary care dental practices DH 2013.

Compliant

Expert Guidance

A local risk assessment has been undertaken to determine which infection prevention and control policies, procedures and protocols are required for the regulated activities provided.

Compliant

Expert Guidance

Sa

Infection prevention and control policy statement is available which outlines compliance with both the Essential Quality Requirements in HTM 01-05 (2013) and the Code of Practice (2015); plus the intention to achieve compliance with Best Practice status in HTM 01-05 (2013).

Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Dental HTM 01-05 (AT007)

Date Approved: 10/06/2016

Expert Guidance

ICAT Audit Tool Vrs 2.0 Page 2 of 22

All healthcare staff have received health and safety information and training with regard to the risk of injury from medical sharps.

Compliant

Legislation

Full compliance

Non compliance

Non applicable

Total (%)

5

0

0

100 %

Demonstration 1 Gordon House Expertise Staff roles and responsibilities, Competent Persons

Question

Compliance

Infection prevention and control support is available

Compliant

There is a nominated lead for Infection prevention and control (IPC Lead).

Compliant

There is a nominated lead for decontamination of re-usable dental instruments/clinical equipment/medical devices (Decontamination Lead).

Non-Compliant

Comments

Rationale

e

Expert Guidance Expert Guidance

Expert Guidance HTM 01-05 Decontamination in primary care dental practices DH 2013 EQR Para 2.4c and Para 9.3; Code of Practice for the prevention and control of infections 2015 Criterion 2

m

pl

There is no named decontamination lead.

Non-Compliant

Staff should have access to Occupational Health for services and advice.

Non-Compliant

Sa

There is a nominated lead for environmental cleaning.

There is no named environmental cleaning lead.

Staff are not aware how to contact Occupational Health.

Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Dental HTM 01-05 (AT007)

Date Approved: 10/06/2016

Expert Guidance Code of Practice for the prevention and control of infections 2015 Criterion 2 Legislation HTM 01-05 Decontamination in primary care dental practices DH 2013 EQR Para 2.6; Code of Practice for the prevention and control of infections 2015 Criterion 10; HSE Health and Safety (Sharp Instruments in Healthcare) Regulations 2013

ICAT Audit Tool Vrs 2.0 Page 5 of 22

Demonstration 1 Gordon House Automated Washer/Disinfector - Practices Automated Washer/Disinfector

Compliance

Comments

Rationale

An automated washer disinfector is installed.

Compliant

Expert Guidance

There is a written procedure/manufacturer's guideline available for the use/operation/validation of the automated washer disinfector.

Compliant

Expert Guidance

Dental instruments are immersed in a detergent/enzymatic solution prior to reprocessing in an automated washer disinfector.

Compliant

Expert Guidance

An appropriate detergent or disinfectant is used for the automated washer disinfector.

Compliant

Legislation

Dental instruments are disassembled prior to reprocessing in an automated washer disinfector.

Compliant

Expert Guidance

Automated washer disinfector is loaded appropriately.

Compliant

Dental instruments are dried after reprocessing in an automated washer disinfector.

Compliant

All dental instruments are visually inspected after reprocessing in an automated washer disinfector to ensure they are clean, functional and in good condition.

Compliant

e

Question

Expert Guidance

pl

Expert Guidance

m

Expert Guidance

Non compliance

Non applicable

Total (%)

8

0

0

100 %

Sa

Full compliance

Demonstration 1 Gordon House

Steriliser - Validation and Maintenance HTM 01-05

Question

Compliance

Comments

Steriliser has an annual validation test certificate, which is available for inspection.

Compliant

Legislation

Periodic (quarterly) testing of the steriliser is performed and is documented.

Compliant

Legislation

A logbook is available for each steriliser.

Compliant

Expert Guidance

Steriliser chart data logger recordings are saved electronically, copied or documented.

Compliant

Expert Guidance

Steriliser daily user checks are performed and documented.

Compliant

Expert Guidance

Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Dental HTM 01-05 (AT007)

Date Approved: 10/06/2016

Rationale

ICAT Audit Tool Vrs 2.0 Page 18 of 22

10/06/2016

Location:

Gordon House 1-6 Station Road Mill Hill London NW7 2JU

Client name:

Demonstration

Notes: Corrective actions: HTM01-05 Essential Quality Requirements Expertise Corrective Action

Reference

pl

Date audited:

e

Infection Control Action Plan

Evidence of Compliance

Responsibility

Due Date

am

There should be a designated named HTM 01-05 Decontamination in primary person as the decontamination lead of re- care dental practices DH 2013 EQR Para usable dental instruments/clinical 2.4c and Para 9.3; Code of Practice for the equipment/medical devices. prevention and control of infections 2015 Criterion 2 Staff should be aware of how to contact Occupational Health for services and advice.

HTM 01-05 Decontamination in primary care dental practices DH 2013 EQR Para 2.6; Code of Practice for the prevention and control of infections 2015 Criterion 10; HSE Health and Safety (Sharp Instruments in Healthcare) Regulations 2013

Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Dental HTM 01-05 (AT007)

Report Version 0.0.1 Date Approved: 10/06/2016

Page 1 of 2

Dental Equipment Reference

Evidence of Compliance

Re-usable tungsten carbide or diamond burrs should be decontaminated using an enzymatic solution or via an AWD after a single use.

HTM 01-05 Decontamination in primary care dental practices DH 2013 Para 1.5, EQR Paras 2.4h; 2.4kii and Para 3.51; Code of Practice for the prevention and control of infections 2015 Criteria 2 and 9

Responsibility

Due Date

pl e

Corrective Action

Re-usable aspirator tips should be HTM 01-05 Decontamination in primary decontaminated either by manually care dental practices DH 2013 Para 1.5, cleaning or using an USC/AWD after each EQR Paras 2.4h; Code of Practice for the use. prevention and control of infections 2015 Criteria 2 and 9

Other Corrective Actions Expertise Reference

There should be a designated named person as the environmental cleaning lead

Code of Practice for the prevention and control of infections 2015 Criterion 2

Evidence of Compliance

m

Corrective Action

Responsibility

Due Date

Responsibility

Due Date

Dental Instrument - Packaging and Storage Corrective Action

Evidence of Compliance

BS EN 150 11607-1:2006; HTM 01-05 Decontamination in primary care dental practices DH 2013 Para 4.22

Sa

Only packaging bearing the appropriate standard BS or CE symbols should be used.

Reference

Pre-wrapped dental instruments should be sterilised in a vacuum steriliser only.

HTM 01-05 Decontamination in primary care dental practices DH 2013 Para 4.22a

An aseptic technique should be used to wrap dental instruments after sterilisation.

HTM 01-05 Decontamination in primary care dental practices DH 2013 Para 4.22b

Copyright IPC Management (Holdings) Ltd Š 2005–2016 Template: Dental HTM 01-05 (AT007)

Report Version 0.0.1 Date Approved: 10/06/2016

Page 2 of 2