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