Infection Control Audits
Part Two
Decontamination
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, sterilization, transport and storage of re-usable and single use instruments?
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yes
no
Has all relevant staff received training for the decontamination procedures which they are expected to perform including correct use of equipment?
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yes
no
Is a record kept of any instruments that cannot be reprocessed in accordance with your local decontamination policy?
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yes
no
Are all wrapped, sterilized instruments dated with the use-by date?
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yes
no
Does the practice have a nominated lead responsible for infection control and decontamination?
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yes
no
Has the registered manager a written statement of duties with specific reference to equipment validation?
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yes
no
Is there a procedure for transportation of instruments to and from other locations that ensures the segregation of contaminated instruments from clean/sterilised instruments?
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yes
no
Are all log books including testing, service, maintenance and repair records retained in the practice for at least 2 years?
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yes
no
Are disposable instrument trays used or if re-usable trays are used are they decontaminated and sterilized after each use?
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yes
no
Are any instruments (used or unused) left on trays at the end of each session decontaminated (washed and sterilized) before further use?
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yes
no
Are instruments that are not decontaminated immediately, kept moist until they are decontaminated?
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yes
no
Are Instruments inspected under illuminated magnification device for cleanliness and condition following cleaning?
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yes
no
Are hand pieces decontaminated in-between each patient in accordance to manufacturer's instructions?
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yes
no
Are separate canisters of lubricant used for unclean, cleaned and sterilized instruments?
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yes
no
Are those handpieces that are manually cleaned/wiped, lubricated with oil before steam sterilization in accordance with manufacturer's instructions?
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yes
no
Are those hand pieces decontaminated by an automated washer disinfector lubricated with oil before steam sterilization in accordance with manufacturer's instructions?
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yes
no
Are those handpieces decontaminated by an automated washer-disinfector with a specific handpiece irrigation system, lubricated with oil before steam sterilization in accordance with manufacturer's instructions?
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yes
no
Are those dental handpieces washed by a specific handpiece washer device, lubricated with oil before steam sterilization in accordance with manufacturer's instructions?
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yes
no
Are all other dental instruments washed in a washer-disinfector before steam sterilization?
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yes
no
Where practices do not have a washer-disinfector, are all instruments cleaned manually before steam sterilization?
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yes
no
Manual Cleaning - Are two sinks or two bowls in a single sink unit, used for cleaning - one for washing and a separate one for rinsing?
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yes
no
Manual Cleaning - Are detergents used specifically formulated for purpose of cleaning instruments?
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yes
no
Manual Cleaning - Is detergent used at a specified concentration according to manufacturer's guidance?
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yes
no
Manual Cleaning - Is the temperature of water 45C or lower?
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yes
no
Manual Cleaning - Where manufacturer's instructions permit are instruments fully submerged when cleaned?
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yes
no
Manual Cleaning - Are brushes used to clean instruments either single use or washed after each use and replaced at manufacturer's recommended interval or when damaged?
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yes
no
Validation and Testing - Are there contractual arrangements to ensure all steam sterilizers are routinely maintained and validated in accordance with HTM requirements or with manufacturer's instructions?
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yes
no
Validation and Testing - Are daily, weekly, quarterly and annual inspection, testing and maintenance records available for steam sterilizers?
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yes
no
Validation and Testing - Is the steam sterilizer removed from service following an unsatisfactory test result until the fault is rectified?
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yes
no
Validation and Testing - Are there contractual arrangements in place to ensure all automated washer-disinfectors are routinely maintained and validated in line with manufacturer's instructions?
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yes
no
Validation and Testing - Are daily, weekly, quarterly and annual validation and testing results recorded for automated washer-disinfectors?
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yes
no
Washer-Disinfectors - Are relevant staff aware of the instrument loading procedure i.e. spray arms are free to rotate, cannulated instruments are correctly loaded?
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yes
no
Washer-Disinfectors - Are cycle parameters recorded?
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yes
no
Sterilizers - Is there a record made of the date, temperature and pressure achieved and satisfactory completion of each cycle?
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yes
no
Sterilizers - Are steam sterilizers used if fault lights are displayed?
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yes
no
Sterilizers - Are pre-wrapped instruments placed only in vacuum type sterilizers?
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yes
no
Sterilizers - Is distilled water, sterile water for irrigation or reverse osmosis (RO) water used in the sterilizer?
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yes
no
Sterilizers - Are opened bottles of sterile or distilled water discarded at the end of each working day?
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yes
no
Sterilizers - Is the reservoir drained and left clean and dry at the end of each day?
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yes
no
Decontamination Environment - Is there a zoned workflow from dirty to clean?
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yes
no
Decontamination Environment - Are there separate, dedicated decontamination room/s which are restricted to those performing decontamination duties?
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yes
no
Decontamination Environment - Are decontamination areas and work surfaces clean and uncluttered?
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yes
no
Decontamination Environment - Is there adequate ventilation in the clean and dirty room/s to service W/D and sterilizer?
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yes
no
Decontamination Environment - Where full mechanical ventilation is used is direction of air, flowing from the clean area to dirty?
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yes
no
Decontamination Environment - Are there procedures in place for the safe transfer of instruments within the practice?
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yes
no
Decontamination Environment - Are instruments maintained in a moist condition between use and decontamination?
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yes
no
Decontamination Environment - If transport containers are in use, are they lidded, clean, leak proof and in good working order?
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yes
no
Decontamination Environment - Are transport containers cleaned, disinfected and dried following each use?
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yes
no
Decontamination Environment - Are instruments processed in non-vacuum (type N) sterilizer dried prior to packing using disposable non-linting cloth?
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yes
no
Decontamination Environment - Does the practice have a system in place to ensure that storage of non-wrapped instruments does not exceed:1 day if stored in a clinical area; or1 week if stored in a non-clinical area (i.e. clinical area not in current use, or in the clean area of a decontamination room)?
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yes
no
Decontamination Environment - Does the practice have a system in place to ensure that the storage of wrapped instruments does not exceed 1 year?
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yes
no
Decontamination Environment - For each instrument is there a system in place to identify storage time, including the date by which they should be used or reprocessed?
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yes
no
Decontamination Environment - Are instruments stored in a dedicated secure, dry and cool environment?
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yes
no
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