WHTM Audit The Audit Tool, Form 2

Transcription

1 WHTM Audit The Audit Tool, Form 2 Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to The relevant chapter or paragraph number of WHTM is noted after each question or statement. References to other guidance are noted at the end of this document. Section A : Policies and procedures including records, logbooks and nominated leads. The following policies and procedures may be included in one document, or they may be individual documents. Either way it is essential that they are up-to date, available to all staff, and used to support good practice. NUMBER STATEMENT/QUESTION Fully 1 The practice has a nominated lead *responsible for infection control and decontamination (Ch 1 and 9) 2 The practice has an identified individual with responsibility and authority to ensure that all staff comply with medical device procedures.(ch 9) 3 Does the practice have a policy or procedure that includes all appropriate aspects of decontamination within the practice e.g. cleaning, disinfection, inspection, packaging, disposal, sterilisation, transport and storage of reusable and single-use instruments? (An infection control policy) (Ch 1) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 1 of 30

2 4 Does the infection control policy include procedures to minimise infection risks associated with the use, maintenance, service and repair of all medical devices? (Ch 1) 5 Does the practice have a policy and procedure/s in place for the prevention and management of blood-borne virus exposure, including management of spillages, sharps and inoculation incidents in accordance with national guidance? (Ch 1 and all Wales Inoculation Injury Guidelines) 6 Is there a readily-accessible protocol in place that ensures staff are dealt with in accordance with national guidance in the event of blood-borne virus exposure? (para 2.6 and all Wales Inoculation Injury Guidelines) 7 Does the practice have a policy and procedure/s for : I. the management and disposal of waste? (Appendix 1) II. the use of Personal Protective Equipment? (Ch 6) III. hand hygiene? (Ch 6) IV. spillages in accordance with COSHH? (para 2.6 and 6.74) V. cleaning and maintaining the environment? (para 6.61 onwards) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 2 of 30

3 8 The practice has policies and procedures in place to ensure all equipment and instruments that cannot be effectively decontaminated with-in practice premises are processed to the appropriate standards e.g., miscellaneous sedation equipment and implant materials (para 8.9 and Ch 2 manufacturers instructions) 9 Has the practice carried out a risk assessment for legionella under the Health & Safety Commission s Legionnaires disease the control of legionella bacteria in water systems: Approved Code of Practice & Guidance (also known as L8)? (para 6.75 and 6.81) 10 Log books are available and up to date for ultrasonic cleaners, sterilizers and washer disinfectors (if used) which include maintenance and repair records (Ch 11,12,13 and 14) 11 Log books are available and up to date for ultrasonic cleaners, sterilizers and washer disinfectors (if used) which include weekly, quarterly and annual test results for WHTM test schedules (Ch 11,12,13,14) *A nominated lead need not necessarily be a dentist, but must be an indemnified GDC registrant such as a DCP or Practice Manager. See Chapter 9, para 9.3 for Registered Manager role. Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 3 of 30

4 Section B. APPLICATION OF POLICIES B(i) SINGLE USE EQUIPMENT NUMBER STATEMENT/QUESTION Fully 12 Single-use instruments are never reprocessed (para 2.17 to 2.19) 13 Are difficult-to-clean instruments/devices (e.g. matrix bands, saliva ejectors, aspirator tips and three-in-one tips etc) identified as single-use? (para 2.20) 14 Endodontic files and reamers are never reused (para 2.21) 15 Disposable single-use covers are discarded after each patient contact (para 6.65) B (ii) SHARPS (Ref The Public Health Wales Standard Infection Precautions Policy and WHTM 07-01, Safe Management of Healthcare Waste) 16 Sharps containers are correctly assembled according to manufacturer s instructions 17 Sharps containers are available at the point of use and positioned safely Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 4 of 30

5 18 In-use sharps containers are labelled with date, location and a signature 19 Needles are never re-sheathed except with the use of an approved re-sheathing device. 20 Are disposable needles and disposable syringes discarded as a single unit? 21 Sharps containers are never filled beyond the indicator mark 22 Are sharps containers locked with the integral lock when filled to the indicator mark? 23 Full sharps containers are stored in a secure facility away from public access 24 The use of safety syringes and other sharps safety devices, as appropriate to clinical practice (e.g. safety IV canulas) has been considered. 25 Do all staff know what to do in the event of a sharps injury? 26 All sharps injuries are recorded in accident book. (para 2.6) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 5 of 30

6 B (iii) INSTRUMENT CLEANING 27 All new reusable instruments are decontaminated prior to use (para 3.4) 28 Instrument trays are appropriately decontaminated prior to use (para 2.14) 29 All instruments (used or unused) left on trays at the end of each session are decontaminated (cleaned/disinfected and sterilised) before further use (para 2.10) 30 Instruments are cleaned prior to disinfection and sterilisation in line with manufacturer s instructions. (Ch 3.0) 31 In practices that do not have a washer-disinfector, are all instruments cleaned manually and/or in an ultrasonic cleaner before steam sterilisation? (para 3.2) 32 There is a separate dedicated sink for handwashing in each room where decontamination of equipment takes place (para 2.4r) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 6 of 30

7 B (iv) DECONTAMINATION ENVIRONMENT 33 In the practice, are there dedicated decontamination areas? OR dedicated decontamination room(s)? 34 If you have separate, dedicated decontamination room/s are they used only for decontamination duties? (para 1.9) 35 Is the decontamination environment segregated from the clinical activity? (para 1.9, 5.1) 36 Are decontamination areas and work surfaces clean and uncluttered? (para 4.29) 37 Is there a clear workflow from dirty to clean activity? (chapter 5) 38 There is adequate ventilation to serve the area containing decontamination equipment (para 6.41 and 6.42) 39 There is adequate ventilation to remove any fumes, including those from chemicals used in cleaning / decontamination (para 6.41 and 6.42) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 7 of 30

8 40 There are no portable fans used in clinical/decontamination areas (in line with good infection control) (para 6.41) 41 Where full mechanical ventilation is used, does the direction of air flow from the clean to dirty area and has it been checked and verified with a report issued?(para 6.45) Section C CLEANING METHODS C (i) MANUAL CLEANING 42 As an interim arrangement, manual cleaning is performed using a two bowl system [preferably colour coded] for the cleaning and rinsing of instrumentation? (para 2.4r) OR The decontamination area has two separate sinks for cleaning and rinsing contaminated instruments? (para 2.4r) 43 Staff do not use clinical gloves for manual cleaning. Heavy duty domestic gloves are used (Ch 16) 44 Instruments are fully immersed during cleaning, in line with manufacturer s advice (para 16.3c) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 8 of 30

9 45 The temperature of water for manual cleaning is monitored to 45 C or lower (para 16.3b) 46 Detergents used are specifically formulated for the cleaning of re-usable dental instruments ( para 16.3) 47 Detergents used for manual cleaning are designed for the manual cleaning of dental instruments.(para 16.3a) 48 Brushes used to clean instruments are single-use or washed after each use and replaced at the manufacturers recommended interval or when damaged (para 16.3f) 49 Instruments that are not decontaminated immediately are kept moist until they are decontaminated (paras 2.15 and 3.5) C (ii) ULTRASONIC CLEANERS 50 Instruments are clearly segregated and placed in instrument baskets or cassettes and fully immersed, ensuring that all surfaces are in contact with the solution (para 3.30) 51 Hinged or jointed instruments are opened prior to placing them in the instruments basket or cassette (3.30) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 9 of 30

10 52 Is the lid of the ultrasonic cleaner closed during cleaning cycles and whilst not in use to prevent contamination of the ultrasonic cleaning solution? (3.30) 53 Instruments are thoroughly rinsed after being cleaned in the ultrasonic cleaner, prior to disinfection and sterilisation (3.30) 54 Is the solution in the chamber emptied either when visibly contaminated or otherwise at the end of every clinical session? (3.30) 55 Is there a maintenance contract in place to ensure the Ultrasonic cleaner is serviced in line with manufacturer s schedule? (para 14.1) 56 Is there a schedule in place to ensure the Ultrasonic cleaner is validated? (para 14.2) 57 Are the records and reports for daily, weekly, quarterly and annual tests available for inspection? (Ch 14) C (iii) WASHER/DISINFECTORS 58 Daily checks are carried out prior to use, i.e. spray arms are free to rotate and drain filter is emptied as required (para 13.4). Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 10 of 30

11 59 Records are kept of these daily checks (para 3.19) 60 Instruments are correctly loaded into the washer/disinfector, clearly segregated (shadowing) and cannulated instruments arranged appropriately and connected to the correct connections on the specified loading carriage. (para 3.17) 61 Is there a daily check in place to compare and monitor variables of a standard operating cycle? (para 13.4) 62 Contractual arrangements are in place to ensure all automated washer-disinfectors are routinely maintained correctly to the manufacturer s instructions and recorded (Ch 13) 63 Contractual arrangements are in place for carrying out the testing requirements as specified in WHTM chapter 13 C (iv) INSPECTION 64 Instruments are inspected under an illuminated magnification device for cleanliness and condition following cleaning (paras 3.18, 3.49, 3.50, 3.52) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 11 of 30

12 C (v)sterilization 65 Instruments that are not clean are returned to the cleaning cycle (para 3.52) 66 Instruments sterilized in a non-vacuum (type N) steriliser are dried appropriately prior to packing using disposable non-linting cloth (para 2.4j) 67 All instruments sterilised in a non- vacuum (type N) bench top sterilizer are unwrapped prior to sterilization (para 4.24b) 68 Instruments sterilized in a vacuum B or S type bench top steriliser are dried and appropriately wrapped prior to sterilization (para 4.24 and 4.25) 69 Packs are inspected to ensure there is no visible moisture present in the packs prior to storage (para 1.25) 70 Are all instruments compatible with the configured sterilization cycle (time and temperature), and the manufacturers instructions? (para 10.23) 71 The sterilizer is correctly loaded as identified in the manufacturers operating manual using appropriate shelving for the instruments being sterilized. (para 4.21) (also see Sterilizer Operating Manual) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 12 of 30

13 72 Freshly distilled water, sterile water for irrigation or reverse osmosis (RO) water are used to generate steam in the steriliser (para 4.13) 73 Are all stored sterilized instruments packaged and dated with the date of sterilisation? (para 4.26) 74 The autoclave reservoir is drained and left clean and dry at the end of each day. (para 4.13) 75 Are opened bottles of sterile or distilled water discarded at the end of each working day? (para 17.6) 76 A record is made of daily checks including date, temperature and pressure achieved and satisfactory completion for each cycle (para 4.18) 77 Documentation is available to provide evidence of sterilizer management, to include daily, weekly, quarterly and annual testing reports, maintenance records and service reports (para 4.15) 78 Is there a maintenance contract in place to ensure the sterilizer is serviced in line with manufacturer s schedule? (para 12.1) 79 Are there systems in place to check that that the maintenance contract is properly met? Ref: Service level agreement Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 13 of 30

14 80 Is there a contract in place to ensure the sterilizer is validated in line with WHTM 01/05? (para 12.2) 81 The practice / organisation has a written scheme of examination and insurance systems in place for steam sterilizers in accordance with the Pressure Systems Safety Regulations? (para 4.12) 82 Are procedures in place to remove Sterilizers from service that fail to meet testing requirements until the fault is rectified (para 4.23) 83 Does the sterilizer have a printer/independent monitor to record data from each cycle used or a manual log to record such data? (para 4.16) C (vi) HANDPIECES 84 Handpieces are decontaminated between each patient in accordance with manufacturers instructions (para 2.4q) 85 Handpieces that are manually cleaned/disinfected are lubricated with oil before steam sterilization in accordance with manufacturers instructions (para 3.55) 86 Handpieces washed by a specific handpiece cleaning device are lubricated with oil before sterilization in accordance with manufacturers instructions (para 2.4q, Ch3 note 2) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 14 of 30

15 87 Handpieces decontaminated by an automated washer disinfector and or with a specific handpiece irrigation system are lubricated with oil before sterilization in accordance with manufacturer s instructions (para 3.24) 88 Are separate canisters of lubricant used for unclean, cleaned and sterilised handpieces / instruments?(para 3.56) C (vii) MISCELLANEOUS 89 Prosthetic and orthodontic appliances are decontaminated before being placed in the patient s mouth.(ch 7) 90 Are disinfectant solutions changed regularly in accordance with manufacturer s guidelines? (para 3.30j) 91 Reusable trays are decontaminated and sterilized after every use OR the practice uses disposable instrument trays (para 2.17, 2.18) 92 Are film holders used in intra-oral radiography subject to decontamination after every patient use in accordance with manufacturers instructions? (para 6.72) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 15 of 30

16 C (viii) SEDATION EQUIPMENT 93 Are ISM flowmeters used and maintained in accordance with original equipment manufacturers or suppliers instructions? 94 Are ISM breathing systems (tubing, masks, nasal hood and nose pieces) used and cleaned in accordance with manufacturers or suppliers instructions? C (ix) CLEANING EQUIPMENT 95 Cleaning equipment is stored in a non-clinical area (para 6.54) 96 Are chlorine-releasing agents available for blood/bodily fluid spillages and used as per manufacturers instructions? (para 6.74) Section D STORAGE AND MOVEMENT OF INSTRUMENTS / MEDICAL DEVICES / OTHER DEVICES D (i) STORAGE 97 Instruments are stored in a dedicated, secure, dry and cool environment (para 4.27 to 4.31) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 16 of 30

17 98 Does the practice have a system in place to record reprocessing dates and storage time for wrapped instruments? (para 2.4k) 99 Instruments wrapped and packed after processing in a type N sterilizer are stored for no more than 1 year (para 2.4k) 100 Instruments wrapped and packed and processed in a type B or S sterilizer are stored for no more than 1 year (para 2.4k) 101 Is there a system in place to ensure that wrapped instruments are stored away from the clinical environment and used in strict rotation? (para 4.29) 102 Intra-oral films, digital sensors and cassettes are handled and stored safely in accordance with manufacturers instructions (para 6.72) D (ii) MOVEMENT WITHIN THE PRACTICE and OUT OF THE PRACTICE 103 There are procedures in place for the safe transfer of instruments within the practice to prevent recontamination (para 2.6) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 17 of 30

18 104 Is there a procedure for transportation of instruments to and from other locations, including domiciliary visits, which ensures the segregation and identification of contaminated instruments from clean/sterilized instruments? (para ) 105 There is a clear policy in place for transport of instruments in and out of the practice (para 2.26 and 2.30) 106 Are impressions, prosthetic and orthodontic appliances decontaminated in the surgery prior to despatch to laboratory in accordance with manufacturer s instructions and in line with postal regulations? (Ch 7 and para 2.31) 107 Instruments sent for repair are labelled to identify that they have been through the decontamination process (para 3.54) 108 Contaminated medical devices are decontaminated prior to inspection, maintenance or repair (para 3.54) 109 If transport containers are in use, are they lidded, clean, leakproof and in good working order? (para 2.27) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 18 of 30

19 110 Are transport containers cleaned, disinfected and dried following each use? (para 2.28) Section E. TRAINING and STAFF SAFETY 111 Have all relevant staff received formal training in relation to para 1.26 i) the decontamination procedures which they are expected to perform including correct use of equipment? ii) cleaning duties? iii) the prevention and management of blood-borne virus exposure? 112 Are staff trained in the use of personal protective equipment as part of the practice induction? (para 6.14) 113 Have all staff attended induction and ongoing training in the process of waste segregation and disposal? (Appendix 1) 114 Have all staff at risk from sharps injuries received training on risk reduction in relation to blood-borne virus transmission and general infection? (para 1.26) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 19 of 30

20 115 A record of all staff training is maintained.(para 1.26) 116 Can decontamination and clinical staff provide documentary evidence of previous successful immunisation with hepatitis B vaccine? (para 2.4p) 117 All inoculation injuries are documented and records maintained. (Ref -PHW. All-Wales Inoculation Injury Guidelines for Primary Care) Section F. QUALITY ASSURANCE F (i) HAND WASHING 118 Are hand hygiene facilities clean and intact (check sinks taps, splash-backs, liquid soap and paper-towel dispensers)? (Ref Public Health Wales Standard Infection Precautions Policy) 119 Are wash-hand basins free from equipment and other utility items? (Ref Public Health Wales Standard Infection Precautions) 120 Are sensor or lever operated (elbow/wrist/foot-operated) mixer taps available at all wash-hand basins in clinical and decontamination areas? (para 6.11) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 20 of 30

21 121 Are thermostatically controlled taps in use? 122 Does the sink have a plug or an overflow and is fitted with a remote running trap? (U-bend is not directly under the plughole) (para 6.11) 123 Good quality liquid soap is available at each wash-hand basin (para 6.12) 124 The soap cartridges within the dispensers are single use and are never refilled. (para 6.12) 125 Bar soap is not used at wash-hand basins (para 6.6) 126 Reusable nail brushes are not present at wash-hand basins (para 6.9 and Appendix 2) 127 Are disposable absorbent paper towels or hand dryers available at all wash-hand basins? (para 6.7) 128 Are hand-cream dispensers with disposable cartridges available for all clinical and decontamination staff? (para 6.8) 129 Skin disinfectant e.g. alcohol gel is available for hand hygiene (Ref The Public Health Wales Standard Infection Precautions Policy and Appendix 2) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 21 of 30

22 130 Is there a separate dedicated hand basin provided for hand hygiene in each surgery where clinical practice takes place? (para 6.11) 131 Laminated or wipe-clean posters promoting hand hygiene are on display (para 6.13) 132 Clinical and decontamination staff i) remove wrist watches, wrist jewellery, rings with stones during clinical and decontamination procedures (para 6.10) ii) Are bare below elbows or use disposable forearm covers (para 6.34) 133 Staff involved in any clinical and decontamination procedures have short nails that are clean and free from nail extensions and varnish.(para 6.9) 134 Is hand hygiene performed before i) donning and after the removal of gloves? (para 6.5) ii) before and after every new patient contact? (para 6.5) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 22 of 30

23 135 Is hand hygiene an integral part of staff induction? (para 6.3) 136 Is hand hygiene training provided periodically throughout the year? (para 6.3) 137 Hand hygiene training records are maintained (para 6.3 and 1.26) F (ii) PERSONAL PROTECTIVE EQUIPMENT (Ref Ch6, 6.14 to 6.37) 138 Are plastic gowns/aprons, goggles, masks or face shields used for any clinical and decontamination procedures where there is a danger of splatter or aerosol formation? 139 Eye protection provided for patients and staff is decontaminated after each episode of patient care 140 Eye protection for staff used during decontamination procedures is cleaned after each session or sooner if visibly decontaminated 141 Items of PPE are stored in accordance with manufacturers instructions Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 23 of 30

24 142 Masks are disposed of as clinical waste after each use 143 Single-use plastic aprons are disposed of as clinical waste 144 All single-use PPE items are disposed of after each episode of patient care 145 Alternatives to latex gloves are available 146 Powder-free CE-marked gloves are used routinely 147 Surgery wear worn by all staff is changed at the end of each day or when visibly contaminated 148 Disposable plastic aprons are worn during all decontamination processes or clinical procedures where there is a risk that clothing/uniform may become contaminated Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 24 of 30

25 149 Are clean, heavy-duty domestic gloves i) available in a range of sizes? ii) Used for domestic cleaning and decontamination procedures where necessary? iii) replaced weekly or more frequently if torn? iv) washed with detergent and hot water and left to dry after each use? (ref Appendix 2) F (iii) KEEPING THE ENVIRONMENT CLEAN 150 Is the overall appearance of the clinical and decontamination environment tidy and uncluttered and is the environment safe for staff to work in? (Ref The Public Health Wales Standard Infection Precautions Policy) 151 Do all floor coverings in clinical and decontamination areas have coved edges that are sealed and impervious to moisture? (para 6.46) 152 Are floor coverings in clinical and decontamination areas impervious and easy-to-clean?(para 6.47) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 25 of 30

26 153 Floors, cupboard doors and accessible high-level surfaces are cleaned daily (para 6.63) 154 Rooms where clinical procedures take place are not carpeted (para 6.46) 155 Are keyboard covers or easy-clean waterproof keyboards used in clinical areas? (para 6.66) 156 Are all surfaces in clinical and decontamination areas impervious and easy to clean? (para 6.46) 157 Are the surfaces of accessible ventilation fittings/grills cleaned weekly? (para 6.64) 158 Are all surfaces (i.e. walls, floors, ceilings, fixtures and fittings, and chairs) free from dust and visible dirt?(para 6.63) 159 Are all work-surface joints intact and seamless with no visible damage? (para 6.46) 160 Are all surfaces (i.e. walls, floors, ceilings, fixtures and fittings, and chairs) free from damage and abrasion? (para 6.39) Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 26 of 30

27 F (iv) DECONTAMINATION OF CLINICAL AREAS 161 Soft toys are not available (para 6.73) 162 The dental chair is free from rips or tears (para 6.62) 163 The dental chair is cleaned between each patient (para 6.62) 164 Are the surfaces of equipment cleaned between each patient (for example, work surfaces, dental chairs, curing lamps, delivery units, inspection handles and lights, spittoons, external surfaces of aspirators and X-ray heads)? (para 6.62) 165 Are all taps, drainage points, splashbacks, sinks, aspirators, drains and spittoons cleaned after every session with a surfactant/detergent? (para 6.63) F (v) WATER SYSTEMS (Paras 6.80 to 6.91 and Ch 19) 166 Are dental unit waterlines and handpieces fitted with antiretraction valves as appropriate? 167 Where bottled water systems are not used, is there a physical air gap separating DUWLs from mains water systems (Type A)? NUMBER STATEMENT/QUESTION Fully 168 Are dental unit waterlines flushed for 2 minutes at the start of each working day and for seconds between Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 27 of 30

28 every patient? 169 Are dental unit waterlines treated with an appropriate biocide according to manufacturer s instructions? 170 Are self-contained water bottles (bottled water system) removed, flushed with distilled or clean RO water and left open to the air for drying on a daily basis and if necessary overnight, and in accordance with manufacturers guidance? 171 For dental surgical procedures involving irrigation, is a separate single-use sterile water source used for irrigation? 172 Is an independent bottled-water system used to dispense fresh distilled, reverse osmosis (RO) or sterile water to supply the DUWL? 173 Are in-line filters cleaned /replaced as per manufacturer s instructions? 174 Does the practice have a written scheme for prevention of legionella contamination in water pipes and other water lines? (para 19.2) NUMBER STATEMENT/QUESTION Fully F (vi) WASTE DISPOSAL (Appendix 1) 175 The Registered Manager (or nominated other) is identified Click here to enter text. Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 28 of 30

29 as being the lead person for waste disposal 176 The Registered Manager is aware of the Hazardous Waste (England and Wales) Regulations and ensures the practice complies with them. 177 The Registered Manager (or nominated other) ensures that waste is:- Click here to enter text. Click here to enter text. i. Correctly segregated ii. iii. iv. Stored safely and securely away from areas of public access Packaged appropriately to be transported Described accurately and fully on the accompanying documents when removed from the premises v. Transferred to an Authorised Person for transport to an authorised waste site vi. Appropriately registered, with necessary records and returns kept in the practice. ( Records and returns means records of any hazardous waste consignment notes etc) Section G Mobile Dental Units (MDU) For Community Dental Services 178 There is a policy for decontamination and disinfection on mobile dental units Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 29 of 30

30 179 Staff working on mobile dental units have been trained in MDU decontamination and disinfection procedures 180 All MDU waste is disposed of according to HB policies 181 MDUs are cleaned externally and internally in line with HB timetable Additional references as noted:- NPHS for Wales. All-Wales Inoculation Injury Guidelines for Primary Care. (NPHS is now Public Health Wales) Public Health Wales Standard Infection Precautions Policy WHTM Safe Management of Health Care Waste Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully with these. Other questions and statements relate to Version 8: 03/02/16 Page 30 of 30