Dentalaudit report

Infection Control Audit Report 08/04/2014

Location:

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

Client name:

Demonstration

Auditor:

Jennifer Day

Accompanied by:

Kevin Malambo

Additional info:

1 x Dental Surgery with no separate decontamination room.

1 x USC and 1 x Vacuum

PL

Decontamination equipment: Steriliser.

E

Date audited:

Section

% Compliance

Governance and Documentary Evidence Expertise Clinical Environment

AM

Clinical Practice

10 % 0% 33 % 91 % 86 %

100 %

Dental Equipment

94 %

Hand Hygiene

84 %

Sharps Management

93 %

Waste Management

79 %

Decontamination of Environment

67 %

Dental Decontamination Room

64 %

Dental Instrument - Decontamination Practices

57 %

Ultrasonic Cleaner - Validation and Maintenance

0%

EX

Clinical Equipment

Ultrasonic Cleaner - Practices

83 %

Automated Washer/Disinfector - Practices

0%

Steriliser - Validation and Maintenance

13 %

Steriliser - Practices

80 %

Dental Instrument - Packaging and Storage

67 %

Transport of Dental Instruments - Dirty

67 %

Transport of Dental Instruments - Reprocessed

100 %

Total

66 %

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

Date Approved:

Report Version 2.0.0 Page 1 of 34

Standard Name

% Score

HTM01-05 Best Practice

0% 48 %

EX

AM

PL

E

HTM01-05 Essential Quality Requirements

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

Date Approved:

Report Version 2.0.0 Page 2 of 34

Transport of Dental Instruments - Dirty

E

Steriliser - Validation and Maintenance

Expertise

Clinical Equipment

Clinical Practice

Staff Records

Decontamination of Environment

Hand Hygiene

Ultrasonic Cleaner - Practices

Dental Instrument - Decontamination Practices

PL

Dental Instrument - Packaging and Storage

Dental Equipment

AM

Steriliser - Practices

Ultrasonic Cleaner - Validation and Maintenance

Clinical Environment

N/A

N/A

N/A

N/A

N/A

N/A

N/A

HTM01-05 Essential Quality Requirements

0%

100 %

100 %

40 %

100 %

0%

0%

100 %

100 %

60 %

Dental Decontamination Room

Governance and Documentary Evidence

EX

Transport of Dental Instruments - Reprocessed

N/A

Automated Washer/Disinfector - Practices

N/A N/A

63 %

Page 3 of 34

Date Approved:

Template: Dental HTM 01-05 (AT007)

N/A N/A

Report Version 2.0.0

Copyright IPC Management (Holdings) Ltd Š 2005–2014

67 % 0%

100 %

50 %

100 %

N/A

0%

N/A N/A

67 %

N/A 0% N/A N/A

0%

HTM01-05 Best Practice

Compliant

Legislation

Single use, CE marked, powderfree sterile gloves are available.

Not applicable

Legislation

Plastic gloves (i.e. polythene) must not be used.

Compliant

Legislation

Heavy duty/ long cuffed gloves used for decontamination processes, are cleaned after each use and replaced weekly.

Compliant

Expert Guidance

Re-usable or disposable single use plastic bibs (apron/napkin) are available for service users.

Compliant

Expert Guidance

Single use, disposable plastic aprons are available when required.

Compliant

Legislation

Plastic aprons are stored in covered containers or are in wall mounted dispensers.

Non-Compliant

Facial protection should be available if splashing of blood, body fluids or chemicals is anticipated.

Compliant

Re-usable facial protection is decontaminated after each use.

Compliant

Appropriate PPE is worn during decontamination procedures or if there is a risk of splashing from blood/body fluids or chemicals.

Non-Compliant

E

Single use, CE marked, powderfree, non-sterile gloves are available in all sizes required by staff.

Expert Guidance HBN 00-09: Infection control in the built environment DH 2013

PL

Aprons are not stored in a suitable lidded container in a cupboard or in a wall mounted dispenser.

Legislation

Expert Guidance

AM

Appropriate PPE is not worn for decontamination processes.

PPE is not worn when there is a risk of splashing with chemicals.

Legislation 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

Compliant

Expert Guidance

After use all Personal Protective Equipment (PPE) should be discarded into a clinical waste bag.

Compliant

Expert Guidance

Sufficient uniforms to allow daily change

Compliant

Expert Guidance

Staff footwear is fully enclosed e.g. no sandals or fenestration (ie with holes cut out) footwear

Compliant

Legislation

EX

Disposable gloves, aprons and facial protection are single use only.

Section Notes

Full compliance

Non compliance

Non applicable

Total (%)

12

2

1

86 %

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

Date Approved:

Report Version 2.0.0 Page 16 of 34

Not applicable

Expert Guidance

Shade guides are cleaned between patient use

Not applicable

Expert Guidance

All endodontic reamers and files are single use or single patient use only.

Compliant

Expert Guidance

Re-usable endodontic reamers and files are re-processed using an AWD or are manually washed separately, followed by sterilisation.

Not applicable

Expert Guidance

Effective traceability procedures are in place to identify individual endodontic reamers and files to the correct service user after decontamination processes.

Not applicable

Expert Guidance

Portable aspirators with reservoir bottles are not used.

Compliant

Suction/aspirator equipment is flushed between service users and disinfected at the end of each session in accordance with manufacturer's recommendations/instructions.

Compliant

Spittoon/cuspidor is clean, in a good state of repair, flushed between service users and is disinfected at the end of each session in accordance with manufacturer's recommendations/instructions.

Compliant

All re-usable intra-oral radiology devices are decontaminated after use, following manufacturer's recommendations/instructions.

Compliant

Devices and materials used for dental impressions, prostheses and orthodontic appliances are disinfected before and after being placed in the service user’s mouth.

Compliant

Dental handpieces are clean, in a good state of repair and reprocessed according to manufacturers instructions after each use.

Non-Compliant

E

Re-usable aspirator tips are clean, in a good state of repair and re-processed according to manufacturers instructions after use.

Expert Guidance

PL

Expert Guidance

Expert Guidance

AM

Expert Guidance

EX

Dental handpieces are cleaned with Mikrozid wipes.

Expert Guidance

Expert Guidance HTM 01-05 Decontamination in primary care dental practices DH 2013 EQR Paras 2.4t; 3.17; 3.20-24; 3.28; 3.55 an 4.7-8; Code of Practice for the prevention and control of infections 2010 Criteria 2 and 9

Separate lubrication canisters are used for dirty, clean or sterilised handpieces/instruments and are clearly labelled.

Compliant

Expert Guidance

The quality of water used for the DUWL meets the requirements for The Water Supply Regulations 2010

Compliant

Expert Guidance

DUWL's using self-contained bottled water systems are flushed with distilled or reverse osmosis water, and the water bottle removed and left open to the air for drying overnight.

Not applicable

Expert Guidance

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

Date Approved:

Report Version 2.0.0 Page 18 of 34