DENTAL PRACTICE VISIT CHECKLIST

Transcription

1 THE PRIMARY CARE TRUSTS OF KENT DENTAL PRACTICE VISIT CHECKLIST EXPLANATORY NOTES Updated 25 February 2011 Page 1 of 16

2 CONTENTS Background and purpose...3 Document ONE...3 Document TWO...3 PREMISES EXTERNAL...5 RECEPTION WAITING ROOM...5 SURGERIES...6 RADIOLOGY...10 Pressure Vessels, Washer Disinfectors, Ultrasonic Baths and Suction Equipment11 Infection Control...11 General/Environmental Cleaning...12 Compressors/Suction...12 Clinical Governance...12 General Health and Safety...12 Updated 25 February 2011 Page 2 of 16

3 DENTAL PRACTICE VISITS Background and purpose Under Paragraph 44, within part 5 of Schedule 3 of the NHS GDS contracts regulations 2005 and the NHS Personal Dental Services Agreements Regulations 2005, Primary Care Trusts (PCTs) are entitled to carry out a visit of any practice premises where practitioners holding a contract for the delivery of NHS dental care are based. Within Kent, practice visits have been carried out for new or relocated practices, practices where there has been a major change in the commissioning arrangements (e.g. a change of practice owner or a newly commissioned surgery) and practices where complaints issues have warranted a visit on grounds of suitability of premises and standards of care etc. With changes in professional governance and regulation and an increasing awareness of the need to monitor quality of service provision, the Kent PCTs, in consultation with the Local Dental Committee (LDC), expressed a desire to bring all practices providing NHS dental care into a rolling programme of regular visits, as has been the case with out medical colleagues for some years now. The aim is that every practice within the Kent PCT area will be inspected every three years. Document ONE must be read by yourself and your practice manager/dental nurse immediately so that action can be taken on any items that need attending to prior to the Dental Practice visit. Document ONE The new checklist is based on the previous one, but there are some additional questions that have been prompted by changes in legislation and increased awareness of the specific health and safety requirements for dental practices. Document Two gives you information relating to questions in Document One. Document TWO The notes to the checklist are intended to give explanation of, and insight into, the reasons behind the questions and have been produced in response to the regularly asked questions that a practices visit usually generates. They may also act as the forum for further discussion and are intended to help the practice owner understand what the inspecting dentist will be seeking during the course of the practice visit. Your practice visit is intended to be a supportive exercise. The practice visit will be undertaken by an experienced dental practitioner who currently works in Kent. The practitioner has undergone training and is fully conversant with the specialised nature of dentistry. The practitioner will be accompanied by a representative from the PCT in your area. After the visit, you will receive a report and there may be a number of comments and/or recommendations. Occasionally, a follow-up visit may be necessary to go over any outstanding issues. Updated 25 February 2011 Page 3 of 16

4 DOCUMENT ONE DENTAL PRACTICE VISIT BY KENT PCTs 1. Date of practice inspection 2. Name of practice owner 3. Name of Dental Practitioner Status Performer Number PCT Performers List on which dentist appears Name of Indemnity Provider and Certificate seen 3a On the attached sheet, please enter the names of all dental nurses, hygienists, therapists and dental technicians employed by the practice. Enter their date of registration with the GDC or, if under training, the course provider and the start date of training. 4. Address of practice premises 5. Address to which report should be sent, if different from above 6. Telephone number Fax number address 7. Name and position of authorised practice visitor 8. Name and position of accompanying PCT personnel in attendance 9. Name of Practice Manager/staff contact Updated 25 February 2011 Page 4 of 16

5 PREMISES EXTERNAL 10. Situation and type of premises: shop, private house, high street, residential or rural (delete as applicable) 11. Is the exterior condition of the property appropriate? 12. Does the provider show an awareness of the Disability Discrimination Act? 12a Access: level/ stairs/ ramp (delete as applicable) 12b Is there access for wheelchairs into any of the surgeries? 13. Are premises clearly indicated in an appropriate manner? 14. Are nameplates clear and appropriate? 15. Is emergency/out-of-hours availability visible from outside? RECEPTION WAITING ROOM 16. Is emergency/out-of-hours availability visible within the waiting room and/or reception? 17. Is there a suitable answerphone message detailing emergency/out-of-hours service? 18. What are the emergency out-of-hours arrangements for the practice? 19. Is a suitable NHS Complaints Policy notice on display? 19a Is a patient complaint leaflet available? 20. Is there a nominated person for dealing with complaints? 21. Is decoration and maintenance acceptable? 22. Is the area clean? 23. Is there suitable and sufficient seating? 24. Is the waiting room monitored? 25. Is the patient information leaflet available and on display and does it conform to the regulations in Schedule 4 of the GDS Regulations 2005? See Annexe 2. 25a Is a NHS patient charge poster displayed? 26. Are the premises appropriately heated? 27. Type of record storage: Open shelves/filing cabinets/rotary etc. 28. Is the security of record storage adequate? 29. Are there sufficient toilets for the number of staff? 30. For all toilets: 30a Are hazardous materials stored at a low level within reach of a minor? 30b Liquid soap? 30c Paper towels? 30d Lidded bin? 30e Hot and cold water? 30f Adequate lighting? 30g Is the patient toilet suitable for wheelchair access? 31. Are toilet doors equipped with locks capable of external operation in an emergency? 32. Is an employer s Public Liability certificate displayed in an area accessible to staff? 32a Does the practice have adequate Public Liability? 33. Does the practitioner have insurance for pressure vessels? Updated 25 February 2011 Page 5 of 16

6 SURGERIES Is decoration and maintenance suitable? 35. Is the flooring suitable? Does the flooring have sealed joints? 36. Are there adequate areas of appropriate work surfaces which are clear of clutter? Are these capable of being easily disinfected? 37. Are there sufficient numbers of hand instruments and are there enough of the following: Mouth mirrors (6) Probes (6) Perio probes (6) Plastics (6) Excavators (6) Scalers (6) Matrices (3) 38. Is there sufficient endodontic instrumentation? 38a Does the practice have a rubber dam kit? 39. Is there a sufficient range of oral surgery instruments, including: Forceps Elevators Scalpels Sutures 40. Are disposable 3-in-1 syringe tips in use? 41. Are disposable saliva ejectors and disposable aspirator tips in use? 42. Are there sufficient disposable or autoclavable LA syringes and disposable needles? 43. Is there a sufficient supply of appropriate impression trays? 43a Are all non-autoclavable impression trays single use? 44. Is there a sufficient supply of handpieces and burs? Please state the number found Air Rotors Contra-angles Straights Burs 45. Are sterilised instruments packaged and stored in accordance with HTM 01-05, especially considering: 45a Appropriate packaging before and after autoclaving? 45b Turn around protocol for sterilised instruments? 45c Storage facilities for sterilised instruments? 46. Is there an autoclave in the surgery? 46a Make and type of machine 46b Serial number Updated 25 February 2011 Page 6 of 16

7 SURGERIES c Are there contractual arrangements to ensure all steam sterilisers are routinely maintained and validated in accordance with HTM requirements or with manufacturers instructions? 46d Date of pressure test 46e Autoclave records: Is there a written log, printout or data capture system recording the date, satisfactory completion of cycle (absence of failure light), temperature/pressure/holding time achieved (and signature of operator for manual records)? 46f Autoclave daily tests Is there: (i) A steam penetration test - Bowie Dick Test (vacuum sterilisers only)? and (ii) An automatic control test (all steam sterilisers) in line with manufacturers instructions? 46g Is reverse osmosis or freshly distilled water available for the autoclave? 47. Is there a practice infection control policy available for inspection? 48. Is there a dedicated hand wash basin? 48a Is there a wall mounted dispenser adjacent/above the hand wash basin for: Liquid soap and Antibacterial based hand rub/gel 48b Is a cleanable poster displayed above each hand basin depicting correct hand hygiene technique? 48c Does the hand wash basin have: A remote running tap No plug No overflow A sensor or lever operated mixer tap A tap which does not discharge directly over the drain aperture 48d Are paper towels available for drying hands? 49. Are there dedicated sinks for instrument cleaning and rinsing or, alternatively, a single sink with two bowls and a common water supply? 49a Are household gloves and disposable aprons available for use when manually cleaning instruments? 49b Is specific surgical instrument detergent used for manual cleaning of instruments? 49c Is chlorhexidene (Hibiscrub) or other detergent (e.g. washing up liquid) used for manual cleaning of instruments? 50. Is zoning practiced within the surgery? Updated 25 February 2011 Page 7 of 16

8 SURGERIES Are handles or tubing capable of being disinfected or sheathed? 52. Is there an ultrasonic bath near each autoclave in each surgery? 52a Are there arrangements in place to ensure all ultrasonic cleaners are maintained and validated in accordance with HTM01-05? 52b Are daily, weekly, quarterly and annual inspection, testing and maintenance records available for ultrasonic cleaners? 53. Is surface disinfectant used? 54. Are disposable cups used? 54a Are they disposed of in the clinical waste? 55. Are there disinfection facilities for impressions and evidence of change of chemical as recommended by the manufacturer? Is cold disinfection used for any items? Are the following available to all clinical staff: Gloves Goggles Masks HS&E Dermatitis (a) Management system (b) Control strategy (c) Health surveillance 58. Are sharps disposed of in rigid containers with yellow lids (EWC code & ) and labelled with date, locality and signature? 59. Does the practice have a policy for the disposal of clinical waste? 59a Are orange bags used for the disposal of soft clinical waste? 59b Are bins foot operated or sensor controlled, lidded and in good working order? 59c Is waste awaiting collection stored in a safe and secure location, away from the public within the practice premises? 60. Is there proper storage and disposal of amalgam waste? 60a Are amalgam filled extracted teeth disposed of in rigid white containers? 60b Is there evidence the practice is segregating waste in accordance with HTM Is an amalgam separator fitted to any waste line which amalgam waste may be discharged into e.g. from spittoons or suction, prior to discharge to the sewer? 62. Is suction apparatus in the surgery adequate? 63. Is the mixer/amalgamator placed on a metal foil lined, lipped tray? 63a Are amalgam capsules used? Updated 25 February 2011 Page 8 of 16

9 SURGERIES Is the surgery suitably ventilated? 65. Is there an x-ray set present in the surgery? 65a Make, model and mounting 65b Serial number 65c Kilo voltage 65d Date of service 65e Date of safety inspection 65f Has an adequate controlled area been defined? 65g Is the x-ray set capable of being isolated from outside the controlled area? 65h Is the x-ray isolation switch appropriately labelled? 65i Are the Local Rules displayed in the surgery by the machine? 65j Are the Local Rules specific for each machine? 66. Are film holders and beam aiming devices available for talking intra-oral radiographs? 67. Is an x-ray viewer available in each surgery? 68. Are the DUWLs treated in accordance with the manufacturers instructions? 68a Are DUWLs flushed for two minutes at the beginning and end of each day and for seconds between each patient? 68b Are DUWLs drained down at the end of each working day or in accordance with manufacturers instructions, where a water treatment system is used? 68c Does the water supply to the spittoon have a physical air gap to prevent back syphonage? 69. Does the practice have a dedicated decontamination facility? 69a Does the design conform to the guidance in HTM b Does the design allow a dirty to clean workflow with a single run of sealed, easily cleaned worktops? 69c Are there dedicated sinks for instrument cleaning and rinsing or, alternatively, a single sink with two bowls and a common water supply? Updated 25 February 2011 Page 9 of 16

10 RADIOLOGY 70. Are there x-ray sets outside the surgery 70a Make and model 70b Serial Number 70c Kilo Voltage 70d Date of service 70e Date of safety inspection 70f Has an adequate controlled area been defined? 70g Is the x-ray set capable of being isolated from outside the controlled area? 70h Is the x-ray isolation switch appropriately labelled? 70i Are the Local Rules displayed by each machine & specific for each machine? 71. Are film holders and beam aiming devices available for taking bitewings and periapicals? 72. Has the HSE been notified by the practice that dental radiography is carried out on the premises? 73. Name of Radiation Protection Supervisor 74. Name of Radiation Protection Advisor 75. Is there written confirmation of an appointed Radiation Protection Advisor? 76. Have the recommendations of the RPA or the safety report been acted upon? 77. Is there a Radiation Protection File available? 78. Has a risk assessment for Ionising Radiation been carried out? 79. Has the surgery appointed a legal person? 80. Are x-rays development facilities considered adequate? N/A Digital only 81. Is there a system for monitoring radiographic solution changing/disposal? N/A Digital only 82. (a) (b) (c) (d) Is there a Quality Assurance System Programme for dental radiology that addresses the following points: Are the number of films taken per dentist recorded? Do any IR(ME)R operators take more than 100 small films per week? If the answer to (b) is YES, is monitoring available Is image quality/audit including action taken regarding unacceptable radiographs? Is patient dose and x-ray equipment, operated in accordance with Local Rules? N/A (e) (f) Dark room films and processing? N/A Digital only (g) Training including 5-yearly IR(MER) courses for all IR(ME)R practitioners and operators? Name Date of Training Updated 25 February 2011 Page 10 of 16

11 Pressure Vessels, Washer Disinfectors, Ultrasonic Baths and Suction Equipment 83. Does the practice have a laser? 83a If yes, is the practice registered with the National Care Standards Commission and all N/A other legislation complied with? 83b Is the practice registered with the Health & Safety Executive for the use of lasers? N/A 84. Autoclaves outside surgeries location of machines 84a 84b 84c 84d Make and type of machine Serial number Are there contractual arrangements to ensure all steam sterilisers are routinely maintained and validated in accordance with HTM requirements or with manufacturers instructions? Date of pressure test 84e Autoclave records: Is there a written log, printout or data capture system recording the date, satisfactory completion of cycle (absence of failure light), temperature/pressure/holding time achieved (and signature of operator for manual records)? 84f Autoclave daily tests Is there: (i) A steam penetration test - Bowie Dick Test (vacuum sterilisers only)? (ii) An automatic control test (all steam sterilisers) in line with instructions? 84g Is reverse osmosis or freshly distilled water available for use in the autoclave? 85. Washer Disinfectors location of machines 85a Make and type of machine 85b Are contractual arrangements in place to ensure all automated washer disinfectors are routinely maintained and validated in accordance with HTM 01-05? 85c Are daily, weekly, quarterly and annual validation and testing results recorded for automated washer disinfectors? 86. Ultrasonic Baths outside surgeries 86a 86b Are there arrangements in place to ensure all ultrasonic cleaners are maintained and validated in accordance with HTM01-05? Are daily, weekly, quarterly and annual inspection, testing and maintenance records available for ultrasonic cleaners? Infection Control 87 Are records of training available for all staff with infection control responsibilities? 87a Is there an infection control policy which includes a named lead staff member for infection control? 87b Are job descriptions available to show infection control responsibilities? 87c 87d Has the practice completed and updated quarterly the self assessment audit for assessing implementation of HTM Has the practice developed a plan that facilitates moving towards best practice? (e) Does the practice have the following policies? Hand hygiene (f) Inoculation injury (h) Manual cleaning of instruments (i) Moving instruments to and fro from separate decontamination areas (j) Selecting new equipment Updated 25 February 2011 Page 11 of 16

12 General/Environmental Cleaning 88 (a) Is there a cleaning schedule which specifies: Areas to be cleaned (b) Frequency of cleaning (c) Materials and equipment to be used (d) Person responsible for this cleaning Compressors/Suction 89 Compressor - Make of machine 89a. Serial number 89b. Date of pressure vessel inspection and testing N/A if pressure/volume is under 250 bar litre 90. Do you have central suction? 90a. Is an amalgam separator fitted to the foul water waste outlet where amalgam waste may be discharged? 90b. If dry-line suction is used, is it adequately exhausted? N/A 90c. If a wet-line suction is used, is this plumbed in via a type A air gap? N/A Clinical Governance 91. Does the practice have an externally accredited clinical governance scheme? 91a. If yes, please give name of the scheme 91b. If no, is there a target date for implementation General Health and Safety 92. Is the secure storage of unused Mercury correct? N/A 93. Is there a mercury spillage retrieval system/kit which is in date? N/A 94. Is there appropriate disposal of radiographic solutions? N/A 95. Are fire regulations observed Are fire exits clearly marked with the correct signs Is there an adequate number of fire extinguishers 96. Is there a fire policy 97. Are there smoke alarms placed within the building? 98. Has an inspection been carried out of all portable electrical appliances? If yes, has a log been kept? 99. Is there an electrical safety certificate for the wiring circuits and fuses within the building? Is there evidence of recommended work carried out? 100. Is there a published Health & Safety Policy which has been signed and dated? N/A 101. Is there a Health & Safety poster on display? 102. Is there an appointed person to administer first aid? 103. Is there a first aid kit? Does it contain an eye bath? 104. Are the Control of Substances Hazardous to Health (COSHH) assessments for materials used in the practice available? Updated 25 February 2011 Page 12 of 16

13 General Health and Safety 105. (a) Have risk assessments been undertaken, including: Slips, trips and falls (b) Electricity at work (c) Pressure valves (d) Fire (e) Ionising radiation (f) Legionella 106. Is there a contract for the disposal of clinical waste? 107. Is there a contract for the disposal of hazardous waste? 107a Are consignment notes kept for three years? 108. Is there a data protection compliant accident reporting book? 109. Is information on Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIIDOR) available? (e.g Are computers used to handle and process personal data? 110a Is the practice registered under the Data Protection Act 111. (a) Child Protection and Safeguarding Children Does the practice have a copy of Child Protection and the Dental Team? (b) Is there a practice policy on child protection? (c) Does the practice have a copy of the relevant Local Safeguarding Children Board Procedures? (d) Does the practice have a customised flowchart of What to do with local contacts of designated nurses and doctors, police, children s social care including the out of hours number, and other relevant numbers (e.g. experienced paediatric dentists)? (e) Is there evidence of training, either completed or booked for all staff in the practice? 112. Does the practice have a publication scheme which complies with the Freedom of Information Act? 113. Is there a practice policy on Violence and Aggression? 114. Are the welfare arrangements for staff suitable? 115. Have all the relevant staff received the recommended immunisations? 116. Is there a written log for confirmation of Hepatitis B vaccinations for staff? Or is an occupational health scheme used? 117. Are drugs (antibiotics) kept securely in a locked cupboard? 118. Are prescription pads, when not in use, kept securely in a locked cupboard? 118a Do you store, administer or prescribe controlled drugs in your practice? 118b If yes, do you have standard operating procedures for each type of controlled drug? Updated 25 February 2011 Page 13 of 16

14 EMERGENCY DRUGS FOR ALL DENTAL PRACTICES DRUG DOSE STOCK ROUTE 119. Adrenaline 1: mg from 1mg/1ml X5 im/sc 120. Midazolam gel 5mg/1ml X5 Buccal or intransal 121. Glucose solution/tablets/gel/powder oral 122. Glucagon injection stored at 1mg X1 iv/im/sc manufacturers recommended temperature 123. Glyceryl trinitrate spray 2 puffs to deliver X1 sublingual 0.4mg MDI/dose 124. Salbutamol inhaler 2 puffs required X1 Inhaled 0.1mg MDI/dose 125. Aspirin dispersable 300mg X5 Oral 126. Is there a system for disposal and replacement of expired drugs? EMERGENCY EQUIPMENT FOR ALL DENTAL PRACTICES 127. Have staff received CPR training recently? 127a If yes, date of last training session 128. A device for administering oxygen under intermittent positive pressure: (a) pocket mask with oxygen valve (b) Self inflating bag valve mask (disposable recommended) 129. Oropharyngeal airways sizes 1,2,3 & Portable suction equipment, which is independent of a power supply 131. Oxygen cylinder with reducing valve, flow meter, tubing, non-rebreathing oxygen mask and suitable connectors. Minimum size D cylinder, 3440 litres is required Is the emergency oxygen cylinder and regulator regularly maintained? 133. Has the oxygen within the cylinder been renewed within three years? 134. Is the regulator capable of delivering a flow rate of at least 10 litres per minute? 135. Disposable syringes (2ml) X4 Disposable needles (23g) X Volumatic spacer for administration of Salbutamol inhaler All of the above items must be available to hand. These lists are in accordance with the recommendations of the Resuscitation Council of the UK. Updated 25 February 2011 Page 14 of 16

15 Dental Practice Inspection Checklist 3a Annexe 1 Annexe 1 Please supply the following information: Names of all dental nurses, hygienists, therapists and dental technicians employed at the practice Job Title Date of registration with the General Dental Council If staff are undergoing training, please supply name of course provider Start date of training Updated 25 February 2011 Page 15 of 16

16 Annexe 2 PATIENT INFORMATION LEAFLET (Dental Practice Inspection Checklist 25) (Details as required by NHS GDS Regulations 2005 Statutory Instrument 2005 No. 3361, Schedule 4) A patient leaflet shall include 1. The name of the contractor. 2. In the case of a contract with a partnership (a) whether or not it is a limited partnership; and (b) the names of all the partners and, in the case of a limited partnership, their status as a general or limited partner. 3. In the case of a contract with a dental corporation (a) the names of the directors, chief executive and secretary of the corporation, in so far as those positions exist in relation to the dental corporation; and (b) the address of the corporation's registered office. 4. The full name of each person performing services under the contract. 5. In the case of each person performing dental services under the contract, his professional qualifications. 6. Whether the contractor undertakes the teaching or training of persons who provide dental services or who intend to do so. 7. The address of each of the practice premises. 8. The contractor's telephone and fax numbers and the address of its website (if any). 9. Whether the practice premises have suitable access for disabled patients and, if not, the alternative arrangements for providing services to such patients. 10. How to request services as a patient. 11. The rights of a patient to express a preference of practitioner in accordance with paragraph 2 of Schedule 3 and the means of expressing such a preference. 12. The services available under the contract. 13. The normal surgery days and hours of the practice. 14. The arrangements for dental services for the hours and days that fall outside normal surgery hours (whether or not provided by the contractor) and how the patient may contact such services. 15. If the services in paragraph 14 are not provided by the contractor, the fact that the Primary Care Trust referred to in paragraph 21 is responsible for commissioning the services. 16. The telephone number of NHS Direct and details of NHS Direct online. 17. How patients may make a complaint or comment on the provision of service. 18. The rights and responsibilities of the patient, including keeping appointments. 19. The action that may be taken where a patient is violent or abusive to the contractor, its staff, persons present on the practice premises or in the place where treatment is provided under the contract or other persons specified in paragraph 3 of Schedule 20. Details of who has access to patient information (including information from which the identity of the individual can be ascertained) and the patient's rights in relation to disclosure of such information. 21. The name, postal and website address and telephone number of the Primary Care Trust which is a party to the contract and from whom details of primary dental services in the area may be obtained. Updated 25 February 2011 Page 16 of 16