Dental action plan

08/04/2014

Location:

Mill Hill Broadway Gordon House Station Road Mill Hill NW7 2JU

Client name:

Demonstration

Notes: Corrective actions: HTM01-05 Essential Quality Requirements Governance and Documentary Evidence

PL

Date audited:

E

Infection Control Action Plan

Reference

Infection prevention and control policy statement should be available which outlines compliance with both the EQR in HTM 01-05 ( 2013) and the Code of Practice ( 2010) and the intention to achieve BP status in HTM 01-05 ( 2013).

HTM 01-05 Decontamination in primary care dental practices DH 2013 EQR/BP and Para 1.19 ; Code of Practice for the prevention and control of infections 2010 Criterion 1

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

HTM 01-05 Decontamination in primary care dental practices DH 2013 EQR Para 2.4 r; Code of Practice for the prevention and control of infections 2010 Appendix B

Evidence of Compliance

EX AM

Corrective Action

Copyright IPC Management (Holdings) Ltd Š 2005–2014 Template: Dental HTM 01-05 (AT007)

Date Approved:

Responsibility

Due Date

Report Version 0.0.1 Page 1 of 14

Decontamination room cleaning schedules should be available to provide information on the type and frequency of cleaning.

HTM 01-05 DH 2013 EQR Para 2.6 and Ch 6; Code of Practice for the prevention and control of infections 2010 Criterion 2; National specifications for cleanliness in the NHS: primary care medical and dental premises NPSA 2010

The practice should have a current contract for regular planned, preventative maintenance of USC's.

HTM 01-05 Decontamination in primary care dental practices DH 2013 EQR Para 2.4n, Ch 11, Ch 12, Ch 13 & Ch 14; Code of Practice for the prevention and control of infections 2010 Criterion 2

E

HTM 01-05 DH 2013 EQR Para 2.6 and Para 6.52; Code of Practice 2010 Criterion 2; Revised Healthcare Cleaning Manual NPSA 2009; National specification for cleanliness in the NHS: primary care medical and dental premises NPSA 2010

PL

Re-usable dental instruments/clinical equipment/medical devices decontamination schedules should be available to provide information on the type and frequency of decontamination.

EX AM

A risk assessment should be completed HTM 01-05 Decontamination in primary for the management of healthcare waste. care dental practices DH 2013 EQR Para 2.4p and Para 2.6; Code of practice for the prevention and control of infections 2010 Criterion 9; HTM 07-01 Safe management of healthcare waste DH 2013 Staff Records

Corrective Action

Reference

There should be documented evidence that staff having direct/indirect service user contact have received infection prevention and control training.

HTM 01-05 Decontamination in primary care dental practices DH 2013 Para 1.22, EQR Para 2.6q and Chs 3, 6, 9, 10, 11, 12, 15 and 19; Code of Practice 2010 Criteria 1, 2, 6 and 10; NICE clinical guideline 139 NICE 2012

Evidence of Compliance

Copyright IPC Management (Holdings) Ltd Š 2005–2014 Template: Dental HTM 01-05 (AT007)

Date Approved:

Responsibility

Due Date

Report Version 0.0.1 Page 3 of 14

Clinical Practice Reference

Evidence of Compliance

Appropriate PPE should be worn during decontamination procedures.

HTM 01-05 DH 2013 EQR Para 2.6 and Para 6.13-14; NICE CG 139 Infection Prevention and control of healthcare associated infections in primary and community care 2012; Personal Protective Equipment at Work Regulations 2005

Reference

PL

Dental Decontamination Room Corrective Action

Responsibility

Due Date

E

Corrective Action

Evidence of Compliance

Responsibility

Due Date

Evidence of Compliance

Responsibility

Due Date

The decontamination room should have HTM 01-05 Decontamination in primary two dedicated decontamination sinks or a care dental practices DH 2013 EQR Para sink with a removable bowl for the 2.4v, Para 5.7, Para 16.1 decontamination of dental instruments.

Dental Instrument - Decontamination Practices Reference

EX AM

Corrective Action

Dental instruments should be reprocessed HTM 01-05 Decontamination in primary using a validated decontamination care dental practices DH 2013 Para 1.7, process.

EQR 2.1-3; Ch 3; Ch 4 Rinsing of dental instruments should be carried out using satifactory potable water.

HTM 01-05 Decontamination in primary care dental practices DH 2013 EQR 2.4v, Para 3.47, Para 16.1, Para 16.3g, Para 17.8, Para 17.10

Dental instruments should be dried prior to reprocessing in a vacuum steriliser.

HTM 01-05 Decontamination in primary care dental practices DH 2013 EQR 2.4k, Para 3.48, Para 4.22-23, Para 16.3h

Copyright IPC Management (Holdings) Ltd Š 2005–2014 Template: Dental HTM 01-05 (AT007)

Date Approved:

Report Version 0.0.1 Page 5 of 14

The dispenser should not be free standing on the work top or the drainer, even if plunger operated and should be wall mounted.

HTM 01-05 Decontamination in primary care dental practices DH 2013 Para 6.5 and 6.11, Appendix 1; HBN 00-09: Infection control in the built environment DH 2013

PL

Sharps Management

E

Hand cream should be available in wall HTM 01-05 Decontamination in primary mounted or pump-operated dispensers in care dental practices DH 2013 Para 6.7, at least one area.

Appendix 1; WHO Guidelines on hand hygiene in healthcare 2009; NICE clinical guideline 139 Infection NICE 2012

Reference

All sharps bins should be temporarily closed when not in use.

HTM 07-01 Safe management of healthcare waste DH 2013; NICE CG 139 Infection Prevention and control of healthcare associated infections in primary and community care 2012

Evidence of Compliance

EX AM

Corrective Action

Responsibility

Due Date

Responsibility

Due Date

Waste Management Corrective Action

Reference

Evidence of Compliance

Extracted teeth and spicules not HTM 07-01 Safe management of healthcare containing amalgam should be disposed of waste DH 2013 in yellow lidded sharps bins.

Orange/yellow waste bags should be labelled with source (i.e. location/department, etc) using a label, numbered tag or an indelible pen.

HTM 07-01 Safe management of healthcare waste DH 2013

The interior of the large yellow storage bin should be free from the contents of split bags and should be cleaned regularly.

HTM 07-01 Safe management of healthcare waste DH 2013; HBN 00-09: Infection control in the built environment DH 2013

Copyright IPC Management (Holdings) Ltd Š 2005–2014 Template: Dental HTM 01-05 (AT007)

Date Approved:

Report Version 0.0.1 Page 11 of 14