South Yorkshire East Midlands by mIT9U1D

VIEWS: 10 PAGES: 30

									                                                      1




                                                                 South Yorkshire East Midlands
                                                  Regional Postgraduate Dental Education Office

SECTION TWO

CLINICAL GOVERNANCE CHECKLIST

Failure to properly complete this document in advance of the Practice Inspection will
affect our ability to proceed with your application to train

VISITORS:            1                                              2
Names & GDC No.


TRAINERS             1                                              2
or Mentor
Names & GDC No.


PRACTICE STAMP                                                      Tel:


                                                                    Trainer/s GDC No/s:



                                                                    Date:

How long have these premises been used as a dental practice? ................................................

PREVIOUS INSPECTIONS:

Date of last PD visit
                              …………………………….

Are all unqualified PCDs in training?          Yes  No

   If Yes, how? (For each staff member in training with full details)




   Has EVERY member of staff undergone a full Practice Induction programme and
   signed to attest to this? Yes  No
                                                  2

PRACTICE DATA

Location
Town Centre            Village              Shopping Area               Residential   

Premises
Purpose Built       Commercial             Converted Dwelling 

Parking
Surgery Car Park           Reserved              Street 

Access
Steps             Ramp                     Handrails           Wide door for wheelchair 
DDA Audit on file?                  Yes                   No 

Security
Alarm system                
Door locks                  
Window locks                
Clinical record storage     

Exterior condition
Excellent         Good                     Average             Poor 

Patient information details displayed outside?
Nameplate         Surgery Opening hours                  Nameplate for all providers       
Emergency contact details       


Number of surgeries       
Disabled access to how many surgeries?        
Full Disabled access to Toilet facilities?         Yes                    No 



Location of surgeries       Ground Floor                  First Floor           Other 
Reception                   Ground Floor                  First Floor           Other 
Waiting Room                Ground Floor                  First Floor           Other 
                                                     3



Facilities in the Practice

Rooms                  Cleanliness   Standard   Sign-     Type of    Comment
                       Poor1-5       of décor   Posted    flooring
                       excellent     1-5        & named
Reception
Size: 4sqm / staff
Waiting Rooms
Size: 7sqm / surgery
X-ray Rooms
Toilets for                                                          DD Access? 
patients
Toilets for                                                          DD Access? 
female staff
Toilets for Male                                                     DD Access? 
staff
Surgery One                                                          DD Access?   
Surgery Two                                                          DD Access?   
Surgery Three                                                        DD Access?   
Surgery Four                                                         DD Access?   
Surgery Five                                                         DD Access?   
Decontaminatio
n room
Play Room
Staff rooms                                                          DD Access? 
Staff changing                                                       DD Access? 
facilities
Other




Comments:




To do list:




Action Plan:
                                                         4

Personnel

Do all members of staff have access to occupational health services?                                      Yes   No
Do all members of staff have evidence of all 7 vaccination seroconversions in their personnel files?      Yes   No
Independent Safeguarding Authority (ISA) (Registration of New Staff from November 2010 -                  Yes   No
existing staff by July 2014)
Do all clinical staff have current Indemnity?                                                             Yes   No
Do all staff have completed CRB checks?                                                                   Yes   No
Do all self employed Dentists have CRB checks?                                                            Yes   No
Do all self employed dentists have indemnity?                                                             Yes   No

Delete as                  Name   Full    Part time or   Registered    Indemnity    CRB       CPR      Qualifications
appropriate                       time    no. of         with GDC?     provider     check?    Cert     and Training
                                          Sessions
Principal Dentist
Trainers
Performer dentist
Trainer
Performer dentists
Performer dentists
Performer dentists
Performer dentists
Specialist dentists
Specialist dentists
Therapists
Hygienists
Hygienists
Dental Nurse
Dental Nurse
Dental Nurse
Dental Nurse
Dental Nurse
Dental Nurse
Dental Nurse
Practice Manager
QAM
Receptionists
Dental technicians
Cleaning staff
Other eg Temporary Staff
Other eg Temporary Staff
Other eg Temporary Staff


Comments:



To do list:



Action Plan:
                                           5

Nominated Persons in the Practice
Responsibility               Name   Date        Relevant training   Date of
                                    Appointed                       Training
Practice Manager
Quality Assurance
Manager (QAM)
First First Aider
Second First Aider
Radiation Protection
Adviser (RPA)
Radiation Protection
Supervisor (RPS)
Nominated lead
responsible for infection
control and
decontamination?
Equipment Validation
Manager
Nominated responsibility
and authority to ensure
that all staff comply with
medical device
procedures.
Data Protection Lead
Complaints & Complaints
Records Lead
Child Protection
Coordinator Lead
Audit Lead
Qualified educator
Other



Comments:




To do list:




Action Plan:
                                              6

Recent Staff Training

Refer to PDP and personnel file for each member of staff

 Which member of   What Training?                 When?    How training      Where is the
 staff?                                                    identified        evidence?
                                                           eg by appraisal




 Comments:




 To do list:




 Action Plan:
                                                      7



Documents Displayed in the Practice

Document                                       Yes   No   Comment
Essential
Patient Information leaflets (PIL) available
for patients
Health & Safety poster
Public liability Insurance
No smoking signs
Appropriate warning signs
Emergency exit signs
Complaints Poster with named person
           st                      st
Name of 1 Aider & Location of 1 Aid box
Desirable
RIDDOR Poster
Manual Handling Poster
First Aid/Resuscitation Poster
Patients Charter
Other




Comments:




To do list:




Action Plan:
                                                  8

Internal Review of the Premises
                      Satisfactory,      Unsatisfactory,     Comment
                      compliant or yes   non- compliant or
                                         No
General conditions
Heating
Lighting
Ventilation
Cleanliness and
tidiness
Communication
Telephone lines
Internal
communication
IT reporting
Recall systems
Privacy (Where?)
For telephone
For conversations
For treatment
discussions
Security
Of clinical records
Of transactions
Of finance details
Of patient
payments
Of IT hardware
and software
Storage
Of consumables
Of Clinical Waste
Of household
waste



Comments:




To do list:




Action Plan:
                                                  9

Surgery equipment - (Use a sheet for each surgery - This can be used as an Inventory and as part
                                            of the Practice Induction process)
Designated surgery name………………………………………………………………………
General condition Score Poor 1 2 3   4  5   Excellent

 Equipment                            Yes   No   Make/Model   Installation   Comment
                                                              Date
 Fixed
 Chair
 Cabinetry
 Dental unit
 Operating light
 Aspirator
 Intra Oral X-Ray
 (See details of Radiographic
 Equipment below)
 Moveable
 Amalgamator / mixer
 Intra oral camera
 Curing light                                                                Last efficiency check
 Laser
 Electrosurgery equipment
 Other
 Instruments
 Conservation
 Periodontology
 Oral Surgery
 Endodontics
 with rubber dam
 Orthodontics
 In cassettes
 On trays
 Sufficient for HTM01-05 turnround?
 Sufficient surgical kits
 Within 21 days turnaround
 Safely stored in sealed bags
 Handpieces per surgery
 3 Air-rotors
 3 Contra-angle
 Straight hand piece for general
 work
 Dedicated sterile straight hand
 piece for surgical work
 Ultrasonic scaler & 3 tips
 Disposable
 PPE, Masks ,Gloves, Bibs.
 Matrix bands
 Impression trays
 Endo files
 3-in-1 tips
 Aspirator tips
 Protection
 Goggles- patient & staff
 Needle resheather
 Mercury spillage kit
                                                  10

Surgery equipment - (Use a sheet for each surgery - This can be used as an Inventory and as part
                                            of the Practice Induction process)
Designated surgery name………………………………………………………………………
General condition Score Poor 1 2 3   4  5   Excellent

 Equipment                            Yes   No   Make/Model   Installation   Comment
                                                              Date
 Fixed
 Chair
 Cabinetry
 Dental unit
 Operating light
 Aspirator
 Intra Oral X-Ray
 (See details of Radiographic
 Equipment below)
 Moveable
 Amalgamator / mixer
 Intra oral camera
 Curing light                                                                Last efficiency check
 Laser
 Electrosurgery equipment
 Other
 Instruments
 Conservation
 Periodontology
 Oral Surgery
 Endodontics
 with rubber dam
 Orthodontics
 In cassettes
 On trays
 Sufficient for HTM01-05 turnround?
 Sufficient surgical kits
 Within 21 days turnaround
 Safely stored in sealed bags
 Handpieces per surgery
 3 Air-rotors
 3 Contra-angle
 Straight hand piece for general
 work
 Dedicated sterile straight hand
 piece for surgical work
 Ultrasonic scaler & 3 tips
 Disposable
 PPE, Masks ,Gloves, Bibs.
 Matrix bands
 Impression trays
 Endo files
 3-in-1 tips
 Aspirator tips
 Protection
 Goggles- patient & staff
 Needle resheather
 Mercury spillage kit
                                                  11

Surgery equipment - (Use a sheet for each surgery - This can be used as an Inventory and as part
                                            of the Practice Induction process)
Designated surgery name………………………………………………………………………
General condition Score Poor 1 2 3   4  5   Excellent

 Equipment                            Yes   No   Make/Model   Installation   Comment
                                                              Date
 Fixed
 Chair
 Cabinetry
 Dental unit
 Operating light
 Aspirator
 Intra Oral X-Ray
 (See details of Radiographic
 Equipment below)
 Moveable
 Amalgamator / mixer
 Intra oral camera
 Curing light                                                                Last efficiency check
 Laser
 Electrosurgery equipment
 Other
 Instruments
 Conservation
 Periodontology
 Oral Surgery
 Endodontics
 with rubber dam
 Orthodontics
 In cassettes
 On trays
 Sufficient for HTM01-05 turnround?
 Sufficient surgical kits
 Within 21 days turnaround
 Safely stored in sealed bags
 Handpieces per surgery
 3 Air-rotors
 3 Contra-angle
 Straight hand piece for general
 work
 Dedicated sterile straight hand
 piece for surgical work
 Ultrasonic scaler & 3 tips
 Disposable
 PPE, Masks ,Gloves, Bibs.
 Matrix bands
 Impression trays
 Endo files
 3-in-1 tips
 Aspirator tips
 Protection
 Goggles- patient & staff
 Needle resheather
 Mercury spillage kit
                                                  12

Surgery equipment - (Use a sheet for each surgery - This can be used as an Inventory and as part
                                            of the Practice Induction process)
Designated surgery name………………………………………………………………………
General condition Score Poor 1 2 3   4  5   Excellent

 Equipment                            Yes   No   Make/Model   Installation   Comment
                                                              Date
 Fixed
 Chair
 Cabinetry
 Dental unit
 Operating light
 Aspirator
 Intra Oral X-Ray
 (See details of Radiographic
 Equipment below)
 Moveable
 Amalgamator / mixer
 Intra oral camera
 Curing light                                                                Last efficiency check
 Laser
 Electrosurgery equipment
 Other
 Instruments
 Conservation
 Periodontology
 Oral Surgery
 Endodontics
 with rubber dam
 Orthodontics
 In cassettes
 On trays
 Sufficient for HTM01-05 turnround?
 Sufficient surgical kits
 Within 21 days turnaround
 Safely stored in sealed bags
 Handpieces per surgery
 3 Air-rotors
 3 Contra-angle
 Straight hand piece for general
 work
 Dedicated sterile straight hand
 piece for surgical work
 Ultrasonic scaler & 3 tips
 Disposable
 PPE, Masks ,Gloves, Bibs.
 Matrix bands
 Impression trays
 Endo files
 3-in-1 tips
 Aspirator tips
 Protection
 Goggles- patient & staff
 Needle resheather
 Mercury spillage kit
                                                  13

Surgery equipment - (Use a sheet for each surgery - This can be used as an Inventory and as part
                                            of the Practice Induction process)
Designated surgery name………………………………………………………………………
General condition Score Poor 1 2 3   4  5   Excellent

 Equipment                            Yes   No   Make/Model   Installation   Comment
                                                              Date
 Fixed
 Chair
 Cabinetry
 Dental unit
 Operating light
 Aspirator
 Intra Oral X-Ray
 (See details of Radiographic
 Equipment below)
 Moveable
 Amalgamator / mixer
 Intra oral camera
 Curing light                                                                Last efficiency check
 Laser
 Electrosurgery equipment
 Other
 Instruments
 Conservation
 Periodontology
 Oral Surgery
 Endodontics
 with rubber dam
 Orthodontics
 In cassettes
 On trays
 Sufficient for HTM01-05 turnround?
 Sufficient surgical kits
 Within 21 days turnaround
 Safely stored in sealed bags
 Handpieces per surgery
 3 Air-rotors
 3 Contra-angle
 Straight hand piece for general
 work
 Dedicated sterile straight hand
 piece for surgical work
 Ultrasonic scaler & 3 tips
 Disposable
 PPE, Masks ,Gloves, Bibs.
 Matrix bands
 Impression trays
 Endo files
 3-in-1 tips
 Aspirator tips
 Protection
 Goggles- patient & staff
 Needle resheather
 Mercury spillage kit
                                       14

Fire Equipment
Date of last Fire Prevention Officer Review …………………… Next………………………
                Type        Location        Condition   Maintenance date
Signage




Emergency
Lighting




Extinguishers




Comments:




To do list:




Action Plan:
                                                          15



Policy Documents on File
Policy                     Yes   Policy   No   Where is this       Reference
                                 Date          document?
                                               In which file and
                                               section?
                                               eg in the BDA
                                               Good Practice or
                                               CQC file
Audit and Peer review                                              GDC ‘Standards for dental professionals’
Autoclave scheme of                                                Pressure Systems and Transportable Gas Container Regulations
Maintenance                                                        1989
See Infection control                                              Use of Transportable Pressure Receptacles Regulations 1996
below                                                              Pressure Systems Safety Regulations 2000
                                                                   HTM01-05
Autoclave                                                          Pressure Systems and Transportable Gas Container Regulations
Inspection certificate                                             1989
                                                                   Provision and Use of Work Equipment Regulations 1998
                                                                   Pressure Systems Safety Regulations 2000
                                                                   The Pressure Systems Safety Regulations 2000
Compressor                                                          Ditto
Child Protection policy                                            Approved Code of Practice
and for Vulnerable
Adults
Complaints                                                         GDS Regulations
Infection Control                                                  Department of Health - Health service guidelines
See Infection control                                              GDC core Subject
below                                                              HTM01-05
Data Protection                                                    Data Protection Act 1998
Decontamination of                                                 Department of Health - Health service guidelines
Impressions                                                        GDC core Subject
See Infection control                                              HTM01-05
below
Display Screen                                                     Health and Safety (Display Screen Equipment) Regulations 1992
Equipment
Emergency collapse                                                 GDC ‘Standards for dental professionals’
Employment policies                                                Department of Trade and Industry employment legislation
                                                                   documentation
Fire precaution policy                                             Fire Precautions (Workplace) regulations 1997
                                                                   The regulatory reform (Fire Safety) Order 2005
Health & Safety Policy                                             Manual Handling Regulations 1992
                                                                   Personal Protective Equipment 1992
                                                                   Personal Protective Equipment at Work Regulations 1992
                                                                   Provision and Use of Work Equipment Regulations 1992
                                                                   Workplace (Health, Safety and Welfare) Regulations 1992
                                                                   Risk assessments in relation to all Health & Safety in the
                                                                   Workplace
Inoculation Injury                                                 Department of Health - Health service guidelines
(Sharps)                                                           Reporting of Injuries Diseases and Dangerous Occurrences
                                                                   Regulations (RIDDOR) 1995
                                                                   HTM01-05
Medical history taking                                             Department of Health - Health service guidelines
Mercury handling                                                   Control of Substances Hazardous to Health Regulations
                                                                   (COSHH) 2002
Out of Hours dental                                                GDS Regulations
services                                                           GDC ‘Standards for dental professionals’
Patient Privacy, Dignity                                           GDC ‘Standards for dental professionals’
& Confidentiality
Nominated person
                                                           16
Radiation Protection                                             The Ionising Radiations Regulations 1999 (IRR99)
- Equipment                                                      The Ionising Radiation (Medical Exposure) Regulations 2000
  malfunction plan                                               [IR(ME)R]
- Justification                                                  NRPB / DoH ‘Guidance Notes for Dental Practitioners on the Safe
                                                                 Use of
- Processing & Filing
                                                                 X-Ray Equipment’ 2001
- Clinical evaluation
                                                                 FGDP Seven Key Skill (Key Skill 4) Audit on radiographs
- QA system & Audit
Staff training                                                   GDP Advisory but see FGDP Seven Key Skill (Key Skill 6)
Especially Induction
training
Waste storage and                                                Carriage of Dangerous Goods (Classification, Packaging and
Disposal                                                         Labelling) Pressure Systems and Transportable Gas Container
- Sharps                                                         Regulations 1989
- Hazardous Waste                                                Waste Disposal: Environmental Protection Act 1991
(Incl waste amalgam &                                            Environmental Protection (Duty of Care) Regulations 1991
processing chemicals)                                            The Hazardous Waste Regulations 2005 (which replace the Special
See Infection control                                            Waste Regulations 1996) and the List of Wastes Regulations 2005
below                                                            that transposes into English law the list of hazardous wastes
                                                                 described in the European Waste Catalogue.
                                                                 HTM01-05
Policy                   Yes   Policy   No   Where is this       Reference
                               Date          document?
                                             In which file and
                                             section?
                                             eg in the BDA
                                             Good Practice or
                                             CQC file
Accident book                                                    Reporting of Injuries, Diseases and Dangerous Occurrences
RIDDOR                                                           Regulations 1995
Whistle blowing policy                                           Public Interest Disclosures Act 1998
Complaints records                                               GDS Regulations
                                                                 GDC ‘Standards for Dental Professionals’
Consumer credit                                                  Consumer Credit Act 1974
license (Advisory)
COSHH Assessments                                                Control of Substances Hazardous to Health Regulations (COSHH)
                                                                 2002
Data Protection                                                  Data Protection Act 1998
registration
Employment Contracts                                             Department of Trade and Industry employment legislation
for all staff                                                    documentation
Discrimination Acts                                              The Equal Pay Act 1970
                                                                 Equal Pay Act (EPA) 1970 (Amendment) Regulations 2003
- Equal pay                                                      Employment Equality (Sexual Orientation) Regulations 2003
- Disability                                                     Disability Discrimination Act 1995
- Sex                                                            The Sex Discrimination Act 1975
- Race Relations                                                 The Race Relations Act 1976
- Civil Partnership                                              Race Relations Amendment Act (2000)
- Employment Equality                                            The Race Relations Act 1976 (Amendment) Regulations 2003
- Age                                                            Civil Partnership Act 2004
                                                                 Employment Equality (Religion or Belief) Regulations 2003
                                                                 Fixed-term Employees (Prevention of Less Favourable
                                                                 Treatment) Regulations
                                                                 The Employment Equality (Age) Regulations 2006
                                                                 Human Rights Act (HRA) 1998
                                                                 Equality Act 2010
                                                                 http://www.equalities.gov.uk/equality_act_2010.aspx
Electrical.                                                      Electricity At Work Regulations 1989
 Installed equipment
test certificates.
Portable appliance
Testing (PAT)
schedule and
inspection documents.
Fire Equipment                                                   Fire Precautions Act 1971
                                                                 Fire Precautions (Workplace) Regulations 1997
                                                                 Fire Precautions (Workplace) (Amendment) Regulations 1999
                                                                 The Regulatory Reform (Fire Safety) Order 2005
                                        17
Freedom of                                     Freedom of Information Act 2000
Information Act
compliance document
Laboratory                                     Medical Devices Regulations 2002
registration.                                  GDS Regulations
Evidence or contract                           GDC ‘Standards for dental professionals’
that your laboratory is
registered with the
MHRA and that
technicians are
registered with the
GDC
Laser Equipment                                Care Standards Act 2000
                                               Medical Devices Agency ‘Guidance on the Safe Use of Lasers in
                                               Medical and Dental Practice’ 1995.
Performing Rights                              Performing Rights Society
license
Radiological
Protection
- Notification to HSE
- Name of RPA
- Name of RPS
- QA document
- Local rules
- Equipment certificate
maintenance check
Risk Assessments                               The Factories Act 1961
See download in                                The Offices, Shops and Railway Premises Act 1963
section 1                                      Health and Safety at Work etc. Act 1974
Waste.                                          Carriage of Dangerous Goods (Classification, Packaging and
- Contracts for                                Labelling) Pressure Systems and Transportable Gas Container
disposal                                       Regulations 1989
- Consignment notes                             Waste Disposal: Environmental Protection Act 1991
for:                                             Environmental Protection (Duty of Care) Regulations 1991
Sharps                                           The Hazardous Waste Regulations 2005 (which replace the Special
Hazardous waste                                Waste Regulations 1996) and the List of Wastes Regulations 2005
                                               that transposes into English law the list of hazardous wastes
See Infection control
                                               described in the European Waste Catalogue.
below
                                                 HTM01-05
Staff Training and        Where is this        To be filed in the relevant personnel files and part of Appraisal
Education policy          document?            process the PDP
documents                 In which file and
                          section?             See Staff Training above on page 11
                          Eg in the BDA Good
                          Practice, HTM 01-
                          05, personnel or
                          CQC file
Clinical governance                            GDS Regulations
arrangements & the                             Management of Health and Safety at Work Regulations 1992
Quality assurance
system.
Name of nominated
person (QAM)
Induction Training for                         Provision and Use of Work Equipment Regulations 1992
all staff                                      Workplace (Health, Safety and Welfare) Regulations 1992
                                               HTM01-05
Orientation                                    Provision and Use of Work Equipment Regulations 1992
Programme for all                              Workplace (Health, Safety and Welfare) Regulations 1992
temporary staff
CPD Records for all                            GDS Regulations
staff                                          GDC ‘Standards for dental professionals’
Ionising Radiation                             The Ionising Radiations Regulations 1999 (IRR99)
training Records                               The Ionising Radiation (Medical Exposure) Regulations 2000
                                               [IR(ME)R]
                                               NRPB / DoH ‘Guidance Notes for Dental Practitioners on the Safe
                                               Use of X-Ray Equipment’ 2001
                                               FGDP Seven Key Skill (Key Skill 4) Audit on radiographs
Staff Training Records                         Management of Health and Safety at Work Regulations 1992
                           18
Staff meeting records           Management of Health and Safety at Work Regulations 1992
Infection control               ALL HTM01-05
Training
See policies in
Section 11 below
But currently:-
Have all staff received
training in relation to
the prevention and
management of blood
borne virus exposure?
Have all relevant staff
received training
which they are
expected to perform
for decontamination
including
correct use of
equipment?
Have staff undertaking
cleaning duties been
fully trained to
undertake such
duties?
Is hand hygiene an
integral part of staff
induction ?
Is hand hygiene
training provided
periodically throughout
the year?
Are staff trained in the
use of personal
protective equipment
as part of the practice
induction?
Have all staff attended
induction and ongoing
training in the process
of waste disposal?



Comments:




To do list:




Action Plan:
                                                              19

Specific Infection Control Policies & Procedures from HTM 01-05
(effective from December 2010)
First complete the IPS self assessment audit (These policies are taken from that document)
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_104543.pdf                       )

 Policy                       Yes   Policy   No   Where is this document?       Reference
                                    Date          In which file and section?
                                                  eg in the BDA Good Practice
                                                  file or HTM 01-05 file
 Infection Control Policy
 1. Prevention of Blood
 Borne virus exposure
 The prevention and                                                             Does the practice have a policy and procedure/s in
 management of                                                                  place for the prevention and management of blood
                                                                                borne virus exposure, including management of
 blood borne
                                                                                spillages, sharps and inoculation incidents in
 virus exposure                                                                 accordance with national guidance?
 Protocol for blood borne                                                       Is there a readily accessible protocol in place that
 virus exposure                                                                 ensures staff are dealt with in accordance with
                                                                                national
                                                                                guidance in the event of blood borne virus
                                                                                exposure?
 2. Decontamination
 Decontamination policy                                                         Does the practice have a policy or procedure that
 or procedure                                                                   includes all appropriate aspects of decontamination
                                                                                within the practice e.g. cleaning, disinfection,
                                                                                inspection, packaging, disposal, sterilization,
                                                                                transport and storage of reusable and single use
                                                                                instruments?
 Procedure for                                                                  Is there a procedure for transportation of instruments
 transportation                                                                 to and from other locations, that ensures the
 of instruments.                                                                segregation
                                                                                of contaminated instruments from clean/sterilised
                                                                                instruments
 3. Environmental design
 and cleaning
 Policy and procedure for                                                       Does the practice have a policy and procedure for
 cleaning and                                                                   cleaning and maintaining the environment?
 maintaining the
 environment
 Procedures for spillage                                                        Does the practice have a local policy and
                                                                                procedures for spillage in accordance with
                                                                                C.O.S.H.H
 4. Hand Hygiene
 Policy for hand hygiene?                                                       Does the practice have a local policy and procedure
                                                                                for hand hygiene?
 5. Management of
 Dental Medical Devices
 infection control policy                                                       Does the practice have an infection control policy
 for                                                                            that includes procedures for the use, maintenance,
  the use, maintenance,                                                         service and repair of all medical devices?
 service, and repair of all
 medical devices?
 A written scheme for                                                           Has the Practice a written scheme for prevention of
  prevention of legionella                                                      legionella contamination in water pipes and other
 contamination                                                                  water-lines?
 6. Personal Protective
 Equipment (PPE)
 A policy and procedure                                                         Does the practice have a policy and procedure/s for
  for the use of personal                                                       the use of personal protective equipment?
 protective equipment?
 7. Waste
 A policy and procedure                                                         Does the practice have a policy and procedure/s for
 for                                                                            the management and disposal of waste?
  the management and
 disposal of waste?
                                                 20

Equipment in a dedicated Local Decontamination Unit (LDU)
Equipment      Location   Type   Make   Serial    Log of regular   Print out   Date of last pressure
                                        Number    testing and      or IT log   test
                                                  inspection
Autoclaves
1
2
3
4
5
Sterilox or
Alpron
Type of                                                                        N/A
Distilled
water
equipment
Ultrasonic
cleaners
1
2
Washer
disinfectors
1
2
2
4
Other




Comments:




To do list:




Action Plan:
                               21



The Plant Room

Equipment      Type   Make   Serial   Test Log   Date of last pressure
                             Number              test
Compressor 1
Filter
Compressor 1
Filter
Central
aspirator 1
Hg separator
Central
aspirator 1
Hg separator
Back up
generator



Comments:




To do list:




Action Plan:
                                                    22

Radiography Equipment                     (referring to both analogue and digital equipment)

 Location                  Type            Make            Model Number




 For each location                  Yes     No      Comment
 Local rules displayed
 Protected location of exposure
 Light plus audible exposure time
 Protected Isolaton switch
 Electronic Timer
 Developing (Delete as
 necessary)
 Manual
 Automatic
 Digital
 Processing logbook
 Intra-oral X-Ray set is 70 Kv?
 Parallel technique holders
 available?
 Rectangular collimation?
 Staff monitoring?


TRAINING
To comply with IR(ME)R each person (Dentist or DCP with an appropriate diploma who is
responsible by law to take radiographs) must undertake 5 hours verifiable CPD on the subject
and complete a radiographic audit every five years.
See Appendix One of section ----for sample audits

 Comments:




 To do list:




 Action Plan:
                                                   23



Waste     (Handling, storage and disposal)

Waste Type       Trained     Type of     Safely    Contract for disposal   Name            Contract
                 handlers?   container   Stored?   accepting               of contracted   Expiry
                                                   responsibility for      transferer      date
                                                   ultimate destination?
                                                   details
Hazardous
Waste
Amalgam
Expired Drugs
Part / Unused
LA
X-ray
chemicals
Other surgery
chemicals
Clinical Waste
Household
Waste



Comments:




To do list:




Action Plan:
                                            24



Medical Emergencies (Resuscitation, CPR and First Aid) See advice in Section One

Equipment                             Yes    No   Comment
Crash trolley?
First Aid Kit
Laerdel Face mask
Ambu bag or equivalent
Portable Oxygen with valve allowing
15 litres + per minute plus face
mask. Safely stored but easily
available. Logged and dated
Independent suction
Automatic external defibrillator
(AED)
Drugs
Emergency drugs available
(See notes for guidance in Section
1)
In date and logged
System to replace expired drugs
Security of Drugs and Prescription
Pads (FP10D)
Training
Basic Life support (BLS)                          Who
                                                  Date
Cardio-Pulmonary resuscitation                    Who
(CPR)                                             Date
Intermediate Life support (ILS)                   Who
                                                  Date
Advanced Life Support (ALS)                       Who
                                                  Date
AED Training
Last full Practice CPR training                   Who
                                                  Date

Comments:



To do list:



Action Plan:
                                             25

The Patient Experience

                      Detail                                                  Yes   No
Patient privacy,      private area for confidential phone calls to patients
dignity and           system to inform patients of undue delay
confidentiality       clear indication of access to out-of-hours service
Handling complaints   complaints system
                      evidence of learning from complaints
                      (e.g. accurate records of any complaints and any
                      outcomes)
Patient information   general patient information eg leaflets
                      system to allow patients to be involved in treatment
                      choice
Patient survey        Audit appointment times, experience at the practice,
                      consent, clear treatment planning etc.
                      Evidence of discussion at practice meetings leading
                      to change
Patient Charter?      See discrimination legislation eg relating to
                      religion, sex, disability, age, employment, a
                      complaints system with named staff in the practice
                      wearing badges etc

Comments:




To do list:




Action Plan:
                                                      26



Significant Event Analysis (SEA)

One of the most significant learning tools in recent years has been the development of the
Significant Event Library being compiled by the Regional Postgraduate Dental Education
Office (RPGDEO). Every practice should discuss significant events and report on them as part
of their clinical governance.

Reporting should be in the following format and filed as part of the Practice Meeting Agenda
for regular review. Turn to the Significant Event Library (SEA) available at the RPGDEO
website www.pgde-trent.co.uk The SEA has a download reporting form:-

Reflection
1. Description of the event
2. The issues raised
3. What went well?
4. What didn’t go well?
5. How might things have been done differently?

Action
1. Areas for Improvement
2. Educational needs identified
3. Which areas will I address and in which order will educational needs be added to PDP?
4. How will I improve these areas and meet those educational needs?
5. How will I be able to demonstrate improvement?

You may wish to plan ahead: Consider Healthcare Failure Mode Effect Analysis HFMEA
www.gha.org/pha/resources/fmea/HFMEA_TELNET_Handout.pdf




See following page for the first cycle of a document audit

Remember, no practice is perfect.

Where there are omissions or issues are unclear, report in the action plan column and bring
the issues or omissions to the attention of the next PRACTICE MEETING and put it on the
agenda.

Be sure to report fully on the meeting. These are the actions of a reflective learning practice.

Make any agreed changes or additions

Undertake a second audit to check the agreed changes.

File the details of the above in your audit file.
                                                                         27

Awareness of Clinical Governance and Health & Safety Measures
Quick document summary and Aide memoire
Key Skill 5 Document list for Health & Safety and other relevant legislation in GDP
KS 5.1 To undertake risk management assessments in the general practice environment                       KS 5.2 See below
AUDIT POINTS Tick if present                                                                      ACTION PLAN and Comments   Page no.
Health and Safety poster (completed) or leaflets on display                          
Patient Information Leaflet available                                                
Practice policy on Health and Safety                                                 
Risk assessments in all areas                                                        

All appropriate signage:-          Emergency Exit                                    
                                   No smoking                                        
                                   X-ray warning                                     
Infection control                  Compliance with BDA A12                           
                                   Compliance with HTM 01-05                         
                          IPS Self assessment audit completed plus Action Plan 
Autoclave maintenance & inspection –
written scheme of examination, and inspection certificate                            
Risk assessments                                                                     

Compressor maintenance & inspection
Written scheme of examination                                                        
Inspection certificate                                                               
Risk assessments                                                                     
Gas cylinders storage and servicing risk assessments                                 
Fire equipment maintenance                                                           
Data Protection registration (IT and paper based)                                    
Freedom of Information Act Registration                                              
Confidentiality contract with all staff members                                      
National Inspection Council for Electrical Installing Contracting (NICEIC) test certificates eg
installed as per manufacturer’s instructions                                         
Portable Electrical Equipment test (3 yearly)                                        
Employer’s liability insurance certificate displayed                                 
GDC Registration for all clinical staff                                              
GDC Registration for all contracted dental technicians                               
Indemnity Certification for dentists, hygienists and therapists                      
Vaccination sero-conversion certification for all staff                              
Occupational Health service appointed and functioning                                
Independent Safeguarding Authority (ISA) registration for all staff (2011)           

Clinical/Hazardous waste transfer contract incl sharps                               
Consignment notes for disposal                                                       
Contract with dental laboratories                                                    
COSHH assessments                                                                    
Records relating to radiation safety
IR(ME)R Certification                                                                
IR(ME)R Risk Assessment                                                              
Check IR(ME)R audit                                                                  
Appointed RPA                                                                        
Appointed RPS                                                                        
Local rules for radiographic equipment next to equipment                             
Staff Monitoring?                                                                    
Laser Regulations adhered to and reported                                            
Awareness of RIDDOR 95 Regulations (Reporting of Injuries,
Diseases and Dangerous Occurrences Regulations)                                      
Risk assessments                                                                     
Accident book                                                                        

Mercury spillage kit                                                                 
First aid box                                                                        
Appointed First-Aider                                                                
First Aider Training Certificate                                                     
Security of drugs and prescription pads kept on premises                             
                                                                   28
Published In-house complaints system displayed                           
Nominated complaints officer                                             
Provision for the disabled and DDA audit assessment for access (seeP1)   
Performing Rights License Certificate displayed?                         
Freedom of Information Act Registration                                  




NAME OF AUDITOR……………………………………………………

DATE OF NEXT REVIEW………………………………………………

BY WHOM………………………………………………………………..
                                                29



                              Clinical Governance
                      Practice Visit Self-Declaration Form


                                       DECLARATION



Address of Practice
(practice stamp)




CQC Registration                        Yes [        ]   No [   ]   Date……………….

CQC visit                               Yes [        ]   No [   ]   Date……………….

BDA Good Practice Accreditation         Yes [        ]   No [   ]   Date……………….


I declare that the electronic evidence scanned into the document above is from original
paperwork maintained in the practice files. (eg a pdf file)



Signature             ________________________________________



Owner, Director or
designated authority. ________________________________________




Name
(Block Capitals)      ________________________________________




Date                   ________________________________________
30

								
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