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). Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. NUMBER STATEMENT/QUESTION Fully compliant NOT fully compliant Evidence Notes 59 Records are kept of these daily checks (para 3.19) Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 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) Click here to enter text. here to enter text. Click here to enter text. here to enter text. 61 Is there a daily check in place to compare and monitor variables of a standard operating cycle? (para 13.4) Click here to enter text. Click here to enter text. Click here to enter text. here to enter text. 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) Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 63 Contractual arrangements are in place for carrying out the testing requirements as specified in WHTM 01.05 chapter 13 Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 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) here to enter text. Click here to enter text. Click here to enter text. here to enter text.
NUMBER STATEMENT/QUESTION Fully compliant NOT compliant Evidence Notes C (v)STERILIZATION 65 Instruments that are not clean are returned to the cleaning cycle (para 3.52) here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 66 Instruments sterilized in a non-vacuum (type N) steriliser are dried appropriately prior to packing using disposable non-linting cloth (para 2.4j) Click here to enter text. Click here to enter text. here to enter text. Click here to enter text. 67 All instruments sterilised in a non- vacuum (type N) bench top sterilizer are unwrapped prior to sterilization (para 4.24b) Click here to enter text. here to enter text. Click here to enter text. Click here to enter text. 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) Click here to enter text. here to enter text. Click here to enter text. Click here to enter text. 69 Packs are inspected to ensure there is no visible moisture present in the packs prior to storage (para 1.25) here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 70 Are all instruments compatible with the configured sterilization cycle (time and temperature), and the manufacturers instructions? (para 10.23) Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 71 The sterilizer is correctly loaded as identified in the manufacturers ‘operating manual’ appropriate shelving for the instruments being sterilized. (para 4.21) (also see Sterilizer Operating Manual) Click here to enter text. Click here to enter text. here to enter text. Click here to enter text. NUMBER STATEMENT/QUESTION compliant NOT fully compliant Evidence Notes
72 Freshly distilled water, sterile water for irrigation or reverse osmosis (RO) water are used to generate steam in the steriliser (para 4.13) here to enter text. here to enter text. Click here to enter text. Click here to enter text. 73 Are all stored sterilized instruments packaged and dated with the date of sterilisation? (para 4.26) Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 74 The autoclave reservoir is drained and left clean and dry at the end of each day. (para 4.13) here to enter text. Click here to enter text. Click here to enter text. here to enter text. 75 Are opened bottles of sterile or distilled water discarded at the end of each working day? (para 17.6) Click here to enter text. Click here to enter text. here to enter text. Click here to enter text. 76 A record is made of checks including date, temperature and pressure achieved and satisfactory completion for each cycle (para 4.18) Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 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) Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 78 Is a maintenance contract in place to ensure the sterilizer is serviced in line with manufacturer’s schedule? (para 12.1) Click here to enter text. here to enter text. Click here to enter text. Click here to enter text. 79 Are there systems in place to check that that the maintenance contract is properly met ? Ref: Service level agreement Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. NUMBER STATEMENT/QUESTION Fully compliant NOT fully compliant Evidence Notes 80 Is there a contract in place to ensure the sterilizer is validated in line with WHTM 01/05? (para 12.2) Click here to enter text. here to enter text. Click here to enter text. Click here to enter text.
96 Are chlorine-releasing agents available for blood/bodily fluid spillages and used as per manufacturers’ instructions? (para 6.74) here to enter text. here to enter text. Click here to enter text. Click here to enter text. 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) Click here to enter text. here to enter text. Click here to enter text. Click here to enter text. NUMBER STATEMENT/QUESTION Fully compliant NOT fully compliant Evidence Notes 98 Does the practice have a system in place to record reprocessing dates and storage time for wrapped instruments? (para 2.4k) Click here to enter text. here to enter text. Click here to enter text. Click here to enter text. 99 Instruments wrapped and packed after processing in a type N sterilizer are stored for no more than 1 year (para 2.4k) Click here to enter text. Click here to enter text. here to enter text. Click here to enter text. 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) Click here to enter text. Click here to enter text. here to enter text. Click here to enter text. 101 Is a system in place to ensure that wrapped instruments are stored away from the clinical environment and used in strict rotation? (para 4.29) Click here to enter text. Click here to enter text. here to enter text. Click here to enter text. 102 Intra-oral films, digital sensors and cassettes are handled and stored safely in accordance with manufacturers’ instructions (para 6.72) Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. D (ii) MOVEMENT WITHIN THE PRACTICE and OUT OF THE PRACTICE
115 A record of all staff training is maintained.(para 1.26) Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 116 Can decontamination and clinical staff provide documentary evidence of previous successful immunisation with hepatitis B vaccine? (para 2.4p) Click here to enter text. Click here to enter text. here to enter text. Click here to enter text. 117 All inoculation injuries are documented and records maintained. (Ref -PHW. All-Wales Inoculation Injury Guidelines for Primary Care) Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Section F. QUALITY ASSURANCE F (i) HAND WASHING 118 Are hand hygiene facilities and intact (check sinks taps, splash-backs, liquid soap and paper-towel dispensers)? (Ref Public Health Wales Standard Infection Precautions Policy) Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 119 Are wash-hand basins free from equipment and other utility items? (Ref Public Health Wales Standard Infection Precautions) Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 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) Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. NUMBER STATEMENT/QUESTION Fully compliant NOT fully compliant Evidence 121 Are thermostatically controlled taps in use? Click here to enter text. Click here to enter text. here to enter text. Click here to enter text.
137 Hand hygiene training records are maintained (para 6.3 and 1.26) Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 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? Click here to enter text. here to enter text. Click here to enter text. Click here to enter text. 139 Eye protection provided for patients and staff is decontaminated after each episode of patient care Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 140 Eye protection for staff used during decontamination procedures is cleaned after each session or sooner if visibly decontaminated here to enter text. Click here to enter text. here to enter text. Click here to enter text. 141 Items of PPE are stored in accordance with manufacturers’ instructions Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. NUMBER STATEMENT/QUESTION compliant NOT fully compliant Evidence Notes 142 are disposed of as clinical waste after each use Click here to enter text. here to enter text. Click here to enter text. here to enter text. 143 Single-use plastic aprons are disposed of as clinical waste Click here to enter text. Click here to enter text. Click here to enter text. here to enter text. 144 All single-use PPE items are disposed of after each episode of patient care Click here to enter text. here to enter text. Click here to enter text. Click here to enter text.
NUMBER STATEMENT/QUESTION Fully compliant NOT compliant Evidence Notes F (vi) WASTE DISPOSAL (Appendix 1) 175 The Registered Manager (or nominated other) is identified as being the lead person for waste disposal Click here to enter text. Click here to enter text. here to enter text. Click here to enter text. 176 The Registered Manager is of the Hazardous Waste (England and Wales) Regulations and ensures the practice complies with them. here to enter text. Click here to enter text. Click here to enter text. here to enter text. 177 The Registered Manager (or nominated other) ensures that waste is:- Correctly segregated 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 Transferred to an Authorised Person for transport to an authorised site Appropriately registered, with necessary records and returns kept in the practice. (“Records and returns” means records of any hazardous waste consignment notes etc) Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. Section G Mobile Dental Units (MDU) For Community Dental Services
178 There is a policy for decontamination and disinfection on mobile dental units Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 179 Staff working on mobile dental units have been trained in MDU decontamination and disinfection procedures Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 180 All MDU waste is disposed of according to HB policies Click here to enter text. Click here to enter text. Click here to enter text. Click here to enter text. 181 MDUs are cleaned externally and internally in line with HB timetable Click here to enter text. Click here to enter text. Click here to enter text. here to enter text. Additional references as noted:- . (NPHS is now Public Health Wales)