WHTM 01-05 Audit Tool
WHTM Form 2
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully
compliant with these.
Other questions and statements relate to continuously improving practice. These are highlighted in yellow.
The relevant chapter or paragraph number of WHTM 01-05 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
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)
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
3
Fully
compliant
Yes
Yes
Yes
NOT fully
compliant
Evidence
Miles Gladson is
responsible for infection
control and
decontamination.
The identified individual that
is responsible is Miles
Gladson.
The infection control policy
is kept behind reception in
the policy file.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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and single-use instruments? (An infection control policy)
(Ch 1)
NUMBER
STATEMENT/QUESTION
Fully compliant
NOT fully compliant
Evidence
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)
Yes
Included in the infection
control policy. All
instruments are
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)
Yes
Kept in policy file under
inoculation injuries
policy. Also procedures
for sharps incidents are
displayed in both
surgeries.
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)
Yes
Kept under infection
control policy. Protocol in
place in surgeries. All
injuries reported to Miles
or Sarah.
Notes
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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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)
Yes
Canon is used for
disposal of waste.
PPE, hand hygiene,
spillages and cleaning
are kept in the policy file.
There is a separate file
kept for waste, COSHH
and a file kept for cleaning
and maintaining the
environment.
All
NUMBER
STATEMENT/QUESTION
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)
Fully
compliant
Yes
NOT fully
compliant
No
Evidence
Notes
Not used in practice.
Safe use of water is in the
policy file. The practice has
undertaken a risk
assessment for Legionella.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
Dental Postgraduate Department  Wales Deanery  8th Floor  Neuadd Meirionnydd  Heath Park  Cardiff  CF14 4YS  T +44 (0) 29 20687830  www.walesdeanery.org/dentistry  Version
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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)
Yes
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)
Yes
Only steriliser is used in
practice. A log book is
available, kept in
decontamination room. File
is kept that includes
maintenance and repair
records.
Log book available for
steriliser which includes test
results for WHTM test
schedules.
*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.
Section B. APPLICATION OF POLICIES
B(i) SINGLE USE EQUIPMENT
NUMBER
STATEMENT/QUESTION
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)
Fully
compliant
Fully
comply.
Yes
NOT fully
compliant
Evidence
List of single-use
instruments are kept in
policy file.
Instruments listed are
identified as single-use in
policy file.
Notes
Click here to enter text.
Click here to enter text.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
Dental Postgraduate Department  Wales Deanery  8th Floor  Neuadd Meirionnydd  Heath Park  Cardiff  CF14 4YS  T +44 (0) 29 20687830  www.walesdeanery.org/dentistry  Version
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Yes
Listed as single-use in
policy file.
B (ii) SHARPS
(Ref The Public Health Wales Standard Infection
Precautions Policy and WHTM 07-01, Safe Management
of Healthcare Waste)
Sharps containers are correctly assembled according to
manufacturer’s instructions
Fully
comply.
17
Sharps containers are available at the point of use and
positioned safely
Fully
comply.
Assembled according to
instructions on side of
sharps container.
Sharps containers are
positioned safely in both
surgeries.
NUMBER
STATEMENT/QUESTION
18
In-use sharps containers are labelled with
date, location and a signature
Fully comply.
All sharps containers are
labelled with date, location
and signed.
19
Needles are never re-sheathed except
with the use of an approved re-sheathing
device.
Yes
Re-sheathing device is
used by both dentists, this
is the only way needles
are re-sheathed.
20
Are disposable needles and disposable
syringes discarded as a single unit?
Yes
.
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)
16
Fully compliant
NOT fully compliant
Evidence
Click here to enter text.
Notes
Disposable syringes not
frequently used in
practice
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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21
Sharps containers are never filled beyond
the indicator mark
Fully comply.
Never filled beyond three
quarters full.
22
Are sharps containers locked with the
integral lock when filled to the indicator
mark?
Yes
23
Full sharps containers are stored in a
secure facility away from public access
Fully comply.
All sharps containers
locked with integral lock
once filled three quarters
of the way.
All stored in areas that
only staff have access to.
24
The use of safety syringes and other
sharps safety devices, as appropriate to
clinical practice (e.g. safety IV canulas)
has been considered.
Yes
Sharps safety devices are
used. Others listed have
been considered.
25
Do all staff know what to do in the event
of a sharps injury?
Yes
26
All sharps injuries are recorded in
accident book. (para 2.6)
Yes
Follow protocol displayed
in surgery and report to
Miles or Sarah.
All injuries are recorded in
the accident book kept
behind recpetion.
NUMBER
STATEMENT/QUESTION
Fully compliant
NOT fully
compliant
Evidence
Notes
B (iii) INSTRUMENT CLEANING
27
All new reusable instruments are
decontaminated prior to use (para
3.4)
Yes
All instruments decontaminated then
bagged before use.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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28
Instrument trays are appropriately
decontaminated prior to use (para
2.14)
Fully comply.
Instruments are always appropriately
decontaminated before use.
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)
Yes
Any instruments left on trays at the end
of each session are immersed in water
with instrument disinfectant before being
taken to be cleaned and sterlised.
30
Instruments are cleaned prior to
disinfection and sterilisation in line
with manufacturer’s instructions.
(Ch 3.0)
Yes
All instruments cleaned according to
manufacturers instructions. They are
immersed in water before disinfection
and sterilisation.
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)
Yes
All instruments are immersed in water
before being cleaned manually, once
cleaned manually then sterilised.
32
There is a separate dedicated sink
for handwashing in each room
Yes
Decontamination room has two sinks
and there is a separate dedicated sink
for hand washing only.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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where decontamination of equipment
takes place (para 2.4r)
NUMBER
STATEMENT/QUESTION
Fully compliant
NOT fully
compliant
Evidence
Notes
B (iv) DECONTAMINATION
ENVIRONMENT
33
In the practice, are there
Fully comply.
There is a dedicated
decontamination room.
dedicated decontamination areas?
OR
dedicated decontamination room(s)?
No
The decontamination room
is also used for stock, the
segregation is well defined
from decontamination and
stock.
No clinical activity takes
place in decontamination
room.
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)
Yes
36
Are decontamination areas and work
surfaces clean and uncluttered?
(para 4.29)
Yes
All surfaces are kept clean
and uncluttered.
37
Is there a clear workflow from dirty to
clean activity?
(chapter 5)
Yes
The workflow is clear from
dirty to clean activity.
This is from the surgery
to decontamination
room.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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38
There is adequate ventilation to
serve the area containing
decontamination equipment (para
6.41 and 6.42)
Yes
The area containing
decontamination equipment
is well ventilated at all
times.
39
There is adequate ventilation to
remove any fumes, including those
from chemicals used in cleaning /
decontamination (para 6.41 and
6.42)
Yes
The decontamination area
is always well ventilated,
removing any fumes
including from chemicals
used in cleaning and
decontamination.
NUMBER
STATEMENT/QUESTION
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)
Fully compliant
Yes
NOT fully
compliant
Evidence
Notes
No fans are used in
clinical/decontamination
areas.
Yes
Air is ventilated directly to
oustide
Section C CLEANING METHODS
C (i) MANUAL CLEANING
42
As an interim arrangement, manual
cleaning is performed using a two
Yes
The decontamination area
has two separate sinks for
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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cleaning and rinsing
contaminated instruments.
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)
Fully comply
Heavy duty gloves are used
for manual cleaning of
instruments.
44
Instruments are fully immersed
during cleaning, in line with
manufacturer’s advice (para 16.3c)
Yes
Instruments are fully
immersed in water during
cleaning according to
manufacturers advice.
NUMBER
STATEMENT/QUESTION
45
The temperature of water for manual
cleaning is monitored to 45°C or
lower (para 16.3b)
Fully comply
46
Detergents used are specifically
formulated for the cleaning of reusable dental instruments ( para
16.3)
Yes
47
Detergents used for manual cleaning
are designed for the manual
Yes
Fully compliant
NOT fully
compliant
Evidence
Notes
The temperature of the water
is monitored when cleaning
instruments. The temperature
is never above 45°C.
Instrument disinfectant is
used for manually cleaning
reusable instruments.
The temperature of the
water is recorded each
time instruments are
manually cleaned.
Detergents used are
specifically used for manual
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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cleaning of dental
instruments only.
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)
Yes
Brushes used are washed
after each use. Replaced
when damaged. Brushes
used for burs are suitable for
sterilisation.
49
Instruments that are not
decontaminated immediately are
kept moist until they are
decontaminated (paras 2.15 and 3.5)
Fully comply.
Before instruments are
cleaned and sterilised they
are immersed in water.
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)
Not used in practice.
51
Hinged or jointed instruments are
opened prior to placing them in the
instruments basket or cassette
(3.30)
Not used in practice.
NUMBER
STATEMENT/QUESTION
Fully compliant
NOT fully
compliant
Evidence
Notes
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
Dental Postgraduate Department  Wales Deanery  8th Floor  Neuadd Meirionnydd  Heath Park  Cardiff  CF14 4YS  T +44 (0) 29 20687830  www.walesdeanery.org/dentistry  Version
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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)
Not used in pracitce.
53
Instruments are thoroughly rinsed
after being cleaned in the ultrasonic
cleaner, prior to disinfection and
sterilisation (3.30)
Not used in practice.
54
Is the solution in the chamber
emptied either when visibly
contaminated or otherwise at the
end of every clinical session? (3.30)
Not used in practice.
55
Is there a maintenance contract in
place to ensure the Ultrasonic
cleaner is serviced in line with
manufacturer’s schedule? (para
14.1)
Not used in practice.
56
Is there a schedule in place to
ensure the Ultrasonic cleaner is
validated? (para 14.2)
Not used in practice.
57
Are the records and reports for daily,
weekly, quarterly and annual tests
available for inspection? (Ch 14)
Not used in practice.
C (iii) WASHER/DISINFECTORS
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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Not used in practice.
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).
NUMBER
STATEMENT/QUESTION
59
Records are kept of these daily
checks (para 3.19)
Not used in practice.
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)
Not used in practice.
61
Is there a daily check in place to
compare and monitor variables of a
standard operating cycle? (para
13.4)
Not used in practice.
62
Contractual arrangements are in
place to ensure all automated
washer-disinfectors are routinely
maintained
Not used in practice.
Fully compliant
NOT fully
compliant
Evidence
Notes
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
Dental Postgraduate Department  Wales Deanery  8th Floor  Neuadd Meirionnydd  Heath Park  Cardiff  CF14 4YS  T +44 (0) 29 20687830  www.walesdeanery.org/dentistry  Version
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correctly to the manufacturer’s
instructions and recorded
(Ch 13)
63
Not used in practice.
Contractual arrangements are in
place for carrying out the testing
requirements as specified in WHTM
01.05 chapter 13
C (iv) INSPECTION
64
Instruments are inspected under an Yes
illuminated magnification device for
cleanliness and condition following
cleaning (paras 3.18, 3.49, 3.50,
3.52)
NUMBER
STATEMENT/QUESTION
Instruments are inspected
before and after
sterilisation.
Fully compliant
NOT fully
compliant
Evidence
If found not to be clean,
instruments are cleaned
and sterilised again.
Notes
C (v)STERILIZATION
65
Instruments that are not clean are Yes
returned to the cleaning cycle (para
3.52)
66
Instruments sterilized in a nonvacuum (type N) steriliser are dried
appropriately prior to packing using
Yes
Instruments that are not
cleaned will begin cleaning
cycle again.
All instruments are dried
before packing.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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disposable non-linting cloth (para
2.4j)
Yes
67
All instruments sterilised in a nonvacuum (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 Yes
the configured sterilization cycle (time
and
temperature),
and
the
manufacturers instructions? (para
10.23)
71
The sterilizer is correctly loaded as Fully comply.
identified in the manufacturers
‘operating manual’ using appropriate
shelving for the instruments being
sterilized. (para 4.21) (also see
Sterilizer Operating Manual)
All instruments are
unwrapped before
sterilisation at all times.
Click here to enter text.
Type N used.
Fully comply.
Instruments are dried before
packing, inspected after
packing to ensure no visible
moisture, then stored away.
All instruments used in
surgery are suitable for
sterilisation cycle, time and
temperature.
The steriliser is correctly
loaded according to the
operating manual. This is to
avoid overloading the
steriliser.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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NUMBER
STATEMENT/QUESTION
Fully compliant
NOT fully
compliant
72
Freshly distilled water, sterile water
for irrigation or reverse osmosis
(RO) water are used to generate
steam in the steriliser (para 4.13)
Fully comply.
Freshly distilled water is
used to generate steam in
the steriliser.
73
Are all stored sterilized instruments
packaged and dated with the date of
sterilisation? (para 4.26)
Yes
All instruments are packed
and dated for a year after
sterilisation.
74
The autoclave reservoir is drained
and left clean and dry at the end of
each day. (para 4.13)
Yes
The autoclave is drained at
the end of every day.
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)
Yes
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)
Yes
No
Evidence
Notes
Distilled water is stored in
the refrigerator. Distilled
water is discarded of after
36 hours.
Date, temperature and
pressure achieved is
recorded every day. The
records are kept in a
logbook in decontamination
room.
Documentation is kept in
autoclave file for annual
testing, maintenance
records and service reports,
behind reception.
Documentation to
provide daily and weekly
testing is stored in the
decontamination room.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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78
Is there a maintenance contract in
place to ensure the sterilizer is
serviced in line with manufacturer’s
schedule? (para 12.1)
Yes
Maintenance contract to
ensure the steriliser is
serviced is with Eschman.
79
Are there systems in place to check
that that the maintenance contract is
properly met ? Ref: Service level
agreement
Yes
The steriliser is serviced
annually.
NUMBER
STATEMENT/QUESTION
80
Is there a contract in place to ensure
the sterilizer is validated in line with
WHTM 01/05? (para 12.2)
Yes
Contract in place with
Eschman.
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)
Yes
System in place with
Eschman.
82
Are procedures in place to remove
Sterilizers from service that fail to
meet testing requirements until the
fault is rectified (para 4.23)
Yes
Sterilisers that fail to meet
testing requirements
Fully compliant
NOT fully
compliant
Evidence
Notes
Documents for the
steriliser are found in the
steriliser file behind
reception.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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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)
Yes
The steriliser has a printer
which is used to log data,
the data is manually logged
daily. Logbook stored in
decontamination room.
C (vi) HANDPIECES
84
Handpieces are decontaminated
between each patient in accordance
with manufacturers’ instructions
(para 2.4q)
Yes
Hand pieces are
decontaminated according
to manufacturers
instructions.
85
Handpieces that are manually
cleaned/disinfected are lubricated
with oil before steam sterilization in
accordance with manufacturers’
instructions (para 3.55)
Yes
Hand pieces are manually
cleaned with alcohol wipes
and lubricated with oil
before sterilisation.
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)
NUMBER
STATEMENT/QUESTION
87
Handpieces decontaminated by an
automated washer disinfector and
or with a specific handpiece
irrigation system are lubricated
Not used in pracitce.
Fully compliant
NOT fully
compliant
Evidence
Click here to enter text.
Hand pieces manually
cleaned.
Notes
Washer disinfector not used
in practice.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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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)
Yes
Separate canisters of
lubricant for unclean and
cleaned instruments are
clearly segregated into dirty
and clean areas.
C (vii) MISCELLANEOUS
Not used in practice.
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)
Yes
Disinfectant solutions are
changed daily in line with
manufacturers guidelines.
91
Reusable trays are decontaminated
and sterilized after every use OR the
practice uses disposable instrument
trays (para 2.17, 2.18)
Yes
Instrument trays are
decontaminated after every
use. The practice also uses
tray paper with reusable
trays.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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92
Are film holders used in intra-oral
radiography subject to
decontamination after every patient
use in accordance with
manufacturers’ instructions? (para
6.72)
NUMBER
STATEMENT/QUESTION
Yes
Film holders are
decontaminated and
sterilised after every use.
Fully compliant
NOT fully
compliant
Evidence
Notes
C (viii) SEDATION EQUIPMENT
93
Are ISM flowmeters used and
maintained in accordance with
original equipment manufacturers’ or
suppliers’ instructions?
Not used in pracitce.
94
Are ISM breathing systems (tubing,
masks, nasal hood and nose pieces)
used and cleaned in accordance
with manufacturers’ or suppliers’
instructions?
Not used in practice.
C (ix) CLEANING EQUIPMENT
95
Cleaning equipment is stored in a
non-clinical area (para 6.54)
Fully comply.
Cleaning equipment is not
stored in clinical areas.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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96
Are chlorine-releasing agents
available for blood/bodily
fluid spillages and used as per
manufacturers’ instructions? (para
6.74)
Yes
Stored in decontamination
room, and used according
to manufacturers
instructions.
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)
NUMBER
STATEMENT/QUESTION
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
Yes
Instruments have a
dedicated, secure, dry and
cool environment.
Fully compliant
Fully comply.
NOT fully
Evidence
compliant
No
This could be improved for
future audits by having a
system to check instrument
dates weekly/monthly.
Notes
Instruments begin
sterilisation cycle again if
they have not been used for
a year.
Type N steriliser used.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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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)
Yes
Wrapped instruments are
stored in cupboards in
surgeries, away from the
clinical environment. They
are used in a strict rotation,
and not used after the date
on sterilised packs.
Not used in practice.
Yes
Instruments must be in
containers that are leak
proof, rigid and close
securely.
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)
NUMBER
STATEMENT/QUESTION
104
Is there a procedure for
transportation of instruments to and
Fully compliant
Yes
NOT fully
compliant
Evidence
Notes
The same procedure
applies as transporting
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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instruments within the
practice, and in addition a
record is made of the date
of the visit, the vehicle used
and the dental instruments
used.
from other locations, including
domiciliary visits, which ensures the
segregation and identification of
contaminated instruments from
clean/sterilized instruments? (para
2.26 – 2.32)
105
There is a clear policy in place for
transport of instruments in and out of
the practice (para 2.26 and 2.30)
Yes
Policy kept in policy file.
Moving instruments to and
from separate
decontamination areas.
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)
Yes
All impressions are
decontaminated prior to
despatch to the laboratory,
in line with the
manufacturers instructions
and postal regulations.
107
Instruments sent for repair are
labelled to identify that they have
been through the decontamination
process (para 3.54)
Yes
Instruments sent for repair
are labelled with a green
sticker that identifies they
have been decontaminated.
108
Contaminated medical devices are
decontaminated prior to inspection,
maintenance or repair (para 3.54)
Yes
Contaminated medical
devices are always
decontaminated before any
inspection, maintenance or
repair.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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109
If transport containers are in use, are
they lidded, clean, leakproof and in
good working order? (para 2.27)
NUMBER
STATEMENT/QUESTION
110
Are transport containers cleaned,
disinfected and dried following each
use? (para 2.28)
Yes
Fully compliant
NOT fully
compliant
Moving instruments to and
from separate
decontamination areas,
policy states that transport
containers must be leak
proof and close securely.
Evidence
Yes
Cleaned and disinfected
after every use with fresh
detergent solution.
Yes
Staff training is received as
part of staff induction
programme. The induction
programme is found in the
policy file, under the staff
section. The policy file is
kept behind reception.
All containers are in
good working order.
Notes
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 bloodborne virus exposure?
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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112
Are staff trained in the use of
personal protective equipment as
part of the practice induction? (para
6.14)
Yes
Use of Personal Protective
Equipment policy.
113
Have all staff attended induction and
ongoing training in the process of
waste segregation and disposal?
(Appendix 1)
Yes
Incorporated at the start of
induction program.
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)
Yes
Training received as part of
induction program.
NUMBER
STATEMENT/QUESTION
115
A record of all staff training is
maintained.(para 1.26)
Yes
116
Can decontamination and clinical
staff provide documentary evidence
of previous successful immunisation
with hepatitis B vaccine? (para 2.4p)
Yes
117
All inoculation injuries are
documented and records
maintained. (Ref -PHW. All-Wales
Yes
Fully compliant
NOT fully
compliant
Evidence
Notes
All staff training is kept in
individual files for each staff
member.
All immunisation records
with hepatitis B vaccine are
stored in immunisation file.
Stored behind reception.
All inoculation injuries are
recorded in accident book
kept behind reception.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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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, splashbacks, liquid soap and paper-towel
dispensers)?
(Ref Public Health Wales Standard
Infection Precautions Policy)
Yes
All hand hygiene facilities
are clean and intact
including sink taps, splashbacks, liquid soap and
paper-towel dispensers.
119
Are wash-hand basins free from
equipment and other utility items?
(Ref Public Health Wales Standard
Infection Precautions)
Yes
All hand basins are free
from equipment and other
utility items.
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)
Yes
All are lever operated,
patient toilet taps are sensor
operated.
NUMBER
STATEMENT/QUESTION
121
Are thermostatically controlled taps
in use?
122
Does the sink have a plug or an
overflow and is fitted with a remote
Fully compliant
NOT fully
compliant
Evidence
No
Yes
Notes
Taps are standard
mixers
Sink has plug and overflow.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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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)
Yes
Anti-bacterial liquid soap is
available at each washhand basin.
These are never refilled.
124
The soap cartridges within the
dispensers are single use and are
never refilled. (para 6.12)
Yes
125
Bar soap is not used at wash-hand
basins (para 6.6)
Fully comply.
Bar soap is not used at any
wash-hand basins.
126
Reusable nail brushes are not
present at wash-hand basins (para
6.9 and Appendix 2)
Fully Comply.
Nail brushes are not used.
127
Are disposable absorbent paper
towels or hand dryers available at all
wash-hand basins? (para 6.7)
Yes
Absorbent paper towels and
hand dryers are available at
wash hand basins.
128
Are hand-cream dispensers with
disposable cartridges available for all
clinical and decontamination staff?
(para 6.8)
Yes
129
Skin disinfectant e.g. alcohol gel is
available for hand hygiene (Ref The
Public Health Wales Standard
Infection Precautions Policy and
Appendix 2)
Fully compliant
Hand cream dispensers
with disposable cartridges
are available for all clinical
staff and decontamination
staff in all surgeries and the
decontamination room.
Skin disinfectant throughout
the practice for staff and
patients.
Used in surgeries and in
patient toilet.
Used in surgeries and in
waiting rooms.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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NUMBER
STATEMENT/QUESTION
130
Is there a separate dedicated hand
basin provided for hand hygiene in
each surgery where clinical practice
takes place? (para 6.11)
Yes
There are two sinks in both
surgeries. In both surgeries
there is a dedicated hand
basin.
131
Laminated or wipe-clean posters
promoting hand hygiene are on
display (para 6.13)
Fully comply.
The posters are displayed
at the dedicated hand basin
in the surgery.
132
Clinical and decontamination staff –
Fully comply.
All clinical and
decontamination staff
always remove any wrist
jewellery, watches and rings
with stones during clinical
and decontamination
procedures. Disposable
forearm covers are not use,
clinical and decontamination
staff are bare below elbows.
Fully comply.
All clinical staff are
compliant, no nail varnish or
nail extensions are worn.
Nails are short and clean.
133
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)
Staff involved in any clinical and
decontamination procedures have
short nails that are clean and free
from nail extensions and
varnish.(para 6.9)
Fully compliant
NOT fully
compliant
Evidence
Notes
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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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)
Yes
Fully compliant
NOT fully
compliant
Hand hygiene is performed
using alcohol gel and anti
bacterial hand wash. There
is a limited amount of times
alcohol gel should be used.
When possible anti bacterial
hand wash should be used.
Alcohol gel is effective
hand hygiene but should
not replace the use of
anti bacterial hand
wash. Alcohol gel should
be used when anti
bacterial hand wash is
not available.
Evidence
Notes
NUMBER
STATEMENT/QUESTION
135
Is hand hygiene an integral part of
staff induction? (para 6.3)
Yes
Found in policy file in
practice team section.
136
Is hand hygiene training provided
periodically throughout the year?
(para 6.3)
Yes
Hand hygiene is provided
annually.
137
Hand hygiene training records are
maintained (para 6.3 and 1.26)
Not fully
compliant.
Hand hygiene records are
not maintained.
To improve for the
future, we will aim to
have hand hygiene
training records.
All listed are always used
where there is a danger of
splatter or aerosol
Used by clinical staff.
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
Fully comply.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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formation. List of PPE is
found in the policy file.
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
Fully comply.
140
Eye protection for staff used during
decontamination procedures is
cleaned after each session or sooner
if visibly decontaminated
Yes
141
Items of PPE are stored in
accordance with manufacturers’
instructions
Yes
NUMBER
STATEMENT/QUESTION
142
Masks are disposed of as clinical
waste after each use
Single-use plastic aprons are
disposed of as clinical waste
Yes
All single-use PPE items are
disposed of after each episode of
patient care
Yes
143
144
Eye protection is
decontaminated using
alcohol wipes or
disinfectant spray.
Eye protection for staff is
replaced is visibly
decontaminated.
All stored according to
manufacturers instructions.
Fully compliant
Yes
Eye protection is always
provided for patients and
staff. Both are
decontaminated after each
episode of patient care.
Eye protection for staff is
used during
decontamination
procedures after each
session.
NOT fully
compliant
Evidence
Notes
Disposed of into clinical
waste after each use.
Disposed of as clinical
waste.
Disposed of after each
episode of patient care, or
replaced sooner if needed.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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Latex gloves are not used in
practice. Only nitrile gloves
are available.
145
Alternatives to latex gloves are
available
146
Powder-free CE-marked gloves are
used routinely
Fully comply.
All gloves used are powderfree.
147
Surgery wear worn by all staff is
changed at the end of each day or
when visibly contaminated
Yes.
Changed at the end of the
day.
148
Disposable plastic aprons are worn
during all decontamination
processes or clinical procedures
where there is a risk that
clothing/uniform may become
contaminated
Yes
When there is a risk of
uniform becoming
contaminated disposable
plastic aprons are worn.
NUMBER
STATEMENT/QUESTION
149
Are clean, heavy-duty domestic
gloves
Fully compliant
Yes
NOT fully
compliant
Evidence
–
–
Disposable plastic
aprons are disposed of
after decontamination
processes or clinical
procedures.
Notes
Available in all
sizes.
Used only for
domestic cleaning
and
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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i)
available in a range of
sizes?
ii)
Used for domestic
cleaning and
decontamination
procedures where
necessary?
iii)
replaced weekly or
moreYEs frequently if
torn?
iv)
washed with detergent
and hot water and left to
dry after each use?
–
–
decontamination
procedures.
Replaced when
damaged.
Washed with
detergent and hot
water, 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)
Yes
The clinical and
decontamination
environment is tidy and
uncluttered and safe for
staff to work in.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
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151
Do all floor coverings in clinical and
decontamination areas have coved
edges that are sealed and
impervious to moisture? (para 6.46)
Yes
All decontamination and
clinical areas have coved
edges that are sealed and
impervious to moisture.
152
Are floor coverings in clinical and
decontamination areas impervious
and easy-to-clean?(para 6.47)
Yes
Yes all areas are impervious
and easy to clean.
NUMBER
STATEMENT/QUESTION
153
Floors, cupboard doors and
accessible high-level surfaces are
cleaned daily (para 6.63)
Fully comply
All are cleaned daily.
154
Rooms where clinical procedures
take place are not carpeted (para
6.46)
Fully comply
No rooms where clinical
procedures take place are
not carpeted.
155
Are keyboard covers or “easy-clean”
waterproof keyboards used in clinical
areas? (para 6.66)
Fully comply
All keyboards have easy
clean covers on them in all
clinical areas.
156
Are all surfaces in clinical and
decontamination areas impervious
and easy to clean? (para 6.46)
Yes
All surfaces in clinical areas
are impervious and easy to
clean.
157
Are the surfaces of accessible
ventilation fittings/grills cleaned
weekly? (para 6.64)
Yes
Accessible fittings are
cleaned.
Fully compliant
NOT fully
compliant
Evidence
Notes
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
Dental Postgraduate Department  Wales Deanery  8th Floor  Neuadd Meirionnydd  Heath Park  Cardiff  CF14 4YS  T +44 (0) 29 20687830  www.walesdeanery.org/dentistry  Version
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158
Are all surfaces (i.e. walls, floors,
ceilings, fixtures and fittings, and
chairs) free from dust and visible
dirt?(para 6.63)
Yes
All surfaces are cleaned
weekly, or before if dirt and
dust is visible.
159
Are all work-surface joints intact and
seamless with no visible damage?
(para 6.46)
Fully comply
All work surface joints are
intact and seamless with no
visible damage.
160
Are all surfaces (i.e. walls, floors,
ceilings, fixtures and fittings, and
chairs) free from damage and
abrasion? (para 6.39)
Yes
All surfaces are free from
damage and abrasion.
NUMBER
STATEMENT/QUESTION
Fully compliant
NOT fully
compliant
Evidence
Cleaning file is used and
ticked when cleaning
has been done. File is
kept behind reception.
Notes
F (iv) DECONTAMINATION OF
CLINICAL AREAS
161
Soft toys are not available (para
6.73)
Fully comply.
There are no soft toys
available.
162
The dental chair is free from rips or
tears (para 6.62)
Fully comply.
Both dental chairs are free
from rips and tears.
163
The dental chair is cleaned between
each patient (para 6.62)
Yes
The dental chair is cleaned
between each patient and at
the end of the day.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
Dental Postgraduate Department  Wales Deanery  8th Floor  Neuadd Meirionnydd  Heath Park  Cardiff  CF14 4YS  T +44 (0) 29 20687830  www.walesdeanery.org/dentistry  Version
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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)
Yes
All listed are cleaned
between each patient.
165
Are all taps, drainage points,
splashbacks, sinks, aspirators,
drains and spittoons cleaned after
every session with a
surfactant/detergent? (para 6.63)
Yes
All listed are cleaned after
every session with a
surfactant/detergent.
Yes
Waterlines and hand pieces
are fitted with anti-retraction
valves.
F (v) WATER SYSTEMS (Paras
6.80 to 6.91 and Ch 19)
166
Are dental unit waterlines and
handpieces fitted with anti-retraction
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
168
Are dental unit waterlines flushed for
2 minutes at the start of each
Bottle water throughout
Fully compliant
NOT fully
Evidence
compliant
No
Waterlines are not flushed
at the start of each working
day because the water is
Notes
Water quality is
monitored through
‘dipslides’
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
Dental Postgraduate Department  Wales Deanery  8th Floor  Neuadd Meirionnydd  Heath Park  Cardiff  CF14 4YS  T +44 (0) 29 20687830  www.walesdeanery.org/dentistry  Version
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chemically treated with
alpron.
working day and for 20–30 seconds
between every patient?
Yes
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?
yes
Distiller used to provide
fresh water daily
173
Are in-line filters cleaned /replaced
as per manufacturer’s instructions?
Yes
174
Does the practice have a written
scheme for prevention of legionella
Yes
Replaced/cleaned
according to manufacturers
instructions.
Prevention of legionella
contamination in water
pipes and other water lines
Not fully
compliant.
The water used is treated
with alpron.
Alpron manufacturers
advocate bottles are not
removed and water
lines purged
Surgical extractions not
done here
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
Dental Postgraduate Department  Wales Deanery  8th Floor  Neuadd Meirionnydd  Heath Park  Cardiff  CF14 4YS  T +44 (0) 29 20687830  www.walesdeanery.org/dentistry  Version
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can be found in the policy
file.
contamination in water pipes and
other water lines? (para 19.2)
NUMBER
STATEMENT/QUESTION
Fully compliant
NOT fully
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
Yes
Miles Gladson is identified
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.
Yes
The practice is fully
compliant with the
Hazardous Waste
Regulations.
177
The Registered Manager (or
nominated other) ensures that waste
is:-
Fully comply.
All waste is correctly
segregated, stored safely
and securely, only staff have
access to these areas.
Waste is packed
appropriately to be
transported.
i.
Correctly segregated
ii.
Stored safely and securely
away from areas of public
access
iii.
Packaged appropriately to be
transported
The Hazardous Waste
file is kept behind
reception.
All waste is described
accurately on the
accompanying documents
when removed from the
premises.
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
Dental Postgraduate Department  Wales Deanery  8th Floor  Neuadd Meirionnydd  Heath Park  Cardiff  CF14 4YS  T +44 (0) 29 20687830  www.walesdeanery.org/dentistry  Version
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iv.
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)
The waste is transferred to
an authorised person for
transport to an authorised
waste site. Waste is taken
by waste disposal company
Canon.
Necessary records and
returns are kept in the
practice in the Hazardous
waste file.
Section G Mobile Dental Units (MDU) For Community Dental Services
178
There is a policy for decontamination
and disinfection on mobile dental
units
N/A
179
Staff working on mobile dental units
have been trained in MDU
decontamination and disinfection
procedures
N/A
180
All MDU waste is disposed of
according to HB policies
N/A
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
Dental Postgraduate Department  Wales Deanery  8th Floor  Neuadd Meirionnydd  Heath Park  Cardiff  CF14 4YS  T +44 (0) 29 20687830  www.walesdeanery.org/dentistry  Version
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181
MDUs are cleaned externally and
internally in line with HB timetable
N/A
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 07-01 Safe Management of Health Care Waste
Most Questions and statements relate to key requirements of good decontamination and you must aim to be fully compliant with these. Other questions and statements relate to
continuously improving practice. These are highlighted in yellow.
Dental Postgraduate Department  Wales Deanery  8th Floor  Neuadd Meirionnydd  Heath Park  Cardiff  CF14 4YS  T +44 (0) 29 20687830  www.walesdeanery.org/dentistry  Version
5: 05/03/14
39