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