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HIW Dental Practice

Inspections

Rebecca Jewell

Primary & Community Healthcare Manager, Healthcare

Inspectorate Wales

Ali Jahanfar, Peer Reviewer

Who we are

HIW is the independent inspectorate and regulator of all healthcare in Wales

What we do

We review and inspect NHS and independent healthcare organisations in

Wales to provide independent assurance for patients, the public, the Welsh

Government and healthcare providers

Our purpose

To provide the public with independent and objective assurance of the quality,

safety and effectiveness of healthcare services, making recommendations to

healthcare organisations to promote improvements.

About HIW

• Patient-centred: we place patients, service users and public experience at

the heart of what we do

• Openness and honesty: in the way we report and in all our dealings with

stakeholders

• Collaboration: building effective partnerships internally and externally

• Professionalism: maintaining high standards of delivery and constantly

seeking to improve

• Proportionality: ensuring efficiency, effectiveness and proportionality in our

approach

Our values

Provide assurance:

Provide independent assurance on the safety, quality and availability of

healthcare by effective regulation and reporting openly and clearly on our

inspections and investigations.

Promote improvement:

Encourage and support improvements in care through reporting and sharing

good practice and areas where action is required.

Strengthen the voice of patients:

Place patient experience at the heart of our inspection and investigation

processes.

Influence policy and standards:

Use our experience of service delivery to influence policy, standards and

practice.

Our outcomes

Our Work

1.This is not intended to be a ‘Gestapo’ type

experience

2. Much more a discussion between professional

colleagues

3. We are listening to your comments and

experiences and acting upon them – where

appropriate

4. We are refining our processes

Give Clear Reassurance that:

• 1. Patient Experience

• 2. Management and Leadership

• 3. Written Documents

• 4. The Environment – internal and external premises

• 5. Standards (IRMER, Medical Emergencies and Waste

• 6. Decontamination Processes

• 7. Clinical Facilities

• 8. Patient Records

The Visit Workbook Components

The Inspection Manager &

The Clinical Reviewer

The Inspection Team

HIW Dental Inspection Programme – the

journey so far…

• Stakeholder Reference Group established including representatives from LHBs, WG, PHW, BDA, GDC and Deanery

• Methodology and reporting style developed

• Clinical Dental Lead (Dr Brent Weller) and Dental Reviewers appointed

• Pilot inspection undertaken to test HIW’s inspection processes

• 2014/15 inspection programme – 75 practices inspected

• 2015/16 inspection programme – 133 practices inspected

Dental Inspection Programme – the

journey so far…

• Positive impact and engagement

• Findings used by Wales

Postgraduate Deanery, Public Health

Wales and Welsh

Government

• First annual report

published in June 2015

• Second annual report to

be published summer 2016

HIW Dental Inspection Programme – the process

BEFORE THE INSPECTION:

• 8 weeks notice by letter

• ‘What to expect from an inspection’ guidance

• List of documents for inspectors to view

• Patient Questionnaires

• Telephone call approximately one week before from inspector

• www.hiw.org.uk/dental-services - workbook and guidance

THE DAY OF THE INSPECTION:

• Inspection team - HIW inspection manager + dentist

• One day on site

• Complete inspection workbook

– Observe (eg decontamination process)

– Talk (speak to patients and all staff)

– Check (documentation and records)

• Immediate verbal feedback

The role of the Peer Reviewer

•The Peer reviewer inspects the following areas

• Radiographic equipment & documentation

• Including the Radiation Protection File,

• The radiation equipment certification for each machine,

• Quality assurance audits

• Records of Radiation Protection Training (IRMER)

• Registration of equipment

• Age of equipment

• Condition

• Location relative to staff/patient positioning?

• Local rules

• Appointed persons?

Radiography Issues

• QA 1,2,3 recording and auditing

• Diagnostic reporting in patient notes

• Film storage if ‘wet’ films

• Data back up if digital

• Start of day wedge testing?

Radiography Issues – Quality Assurance

Daily Wedge Tests?

• Resuscitation and First Aid

• Practice resuscitation policy

• Up to date training in CPR

• Appointed first aider

• Does the practice has adequate resuscitation equipment?

• Are all emergency drugs within date?

• Log book to show regular checks of emergency drugs and resuscitation equipment.

• What systems are in place to ensure the security of drugs and prescription pads?

• Decontamination of instruments and compliance with WHTM01-05

• Daily maintenance programme including log books for checking each autoclave, start and end of day checks.

• Pre-cleaning methods

• Washer – disinfector

• Ultrasonic bath

• Manual cleaning

• Instrument storage including transport between surgeries and decontamination room

• Hand washing facilities available?

• Designated contamination room available?

• Decontamination training protocol with individual records

• Routine audits of infection control requirements WHTM01-05

• Inspection certificates for autoclaves

• Basic cleanliness issues

• Work surfaces clear

• Sealed surfaces

• Sealed flooring

• Important to separate what is essential and what is advisable/desirable/ ‘Gold Standard’

Cross Infection Control

Clutter – worth commenting on but hardly a reportable

issue!

Rethinking and tidying needed

Less Clutter

Wipe clean keyboard

• AUTOCLAVE ISSUES

• Type B, N or S?

• (B- pre-wrapped and storage 12 months)

• (N- post wrapped and storage 12 months)

• (S- see manufacturer’s guidance)

• Type B may be best but not compulsory

Cross Infection Control

• Location

• Use of a ‘Sterilising room’ / CSSD

• Autoclaves still in surgeries?

Autoclaves

Clear Labelling and Expiry Dates

We All Make Mistakes!!

• Pre soaking?

• PPE

• Ultrasonic cleaning

• Manual cleaning

• Visual Inspection – good light + magnification

• Use of washer-disinfectors?

Pre- Autoclave Cleaning Process

Clear Visual Inspection

Hand Cleaning and Instructions

• Where?

• How long?

Post Sterilisation Storage

Storage away from surgery - labelled

Autoclaving of Ultrasonic Tips AND Handpieces

• Handling, storage and disposal or clinical and non-clinical waste

• Contracts in place for clinical waste, amalgam waste, sharps, non-clinical waste

• Where is the clinical waste stored?

• Is the clinical waste stored securely?

• What happens to unused medicine?

• Extracted teeth with/without amalgam

• Domestic waste such as black bags

• Amalgam separators installed?

• Clinical waste

• Contaminated

• Teeth

• Amalgam waste

• Amalgam capsules

• Lockable storage?

Waste Storage

• Management

• Needle resheathing? Or not?

• Holders

• Sharps containers and location

Sharps

• Clinical Facilities

• Dental Surgeries

• Dental unit and cabinetry in good condition?

• Is the surgery clean?

• X-ray equipment

• Local rules visible

• Film holding kit available

• Dental Equipment and Instruments

• Sufficient number of fast, slow and straight handpieces

• Ultrasonic scaler and tips

• Surgical kit

• Filling mixer

• Disposable or single use items.

• Regular serving of compressor

• Recording of audits

• Which are being done?

• Which are essential

• NB some contain confidential data that we do

not need to view

• Should be recorded

• And available on the day to view

• Staff training and updates

• CPR Training – when and who?

• Defibrillator - Compulsory or not?

CPD Records

• Ensure that

• 1. BPEs are being recorded and updated

• 2. Treatments prescribed match the BPE score

BPEs and Periodontal Care

• Patient records

• Previous dental history

• Social history including alcohol and tobacco use

• Smoking cessation advice offered?

• Reason for attendance

• Symptoms

• Initial medical history signed and dated by patient.

• Updated medical history for each course of treatment

• Full Base charting

• Baseline BPE recorded

• Oral cancer screening

• Treatment planning evidence

• Treatment options recorded

• Informed consent

• Treatment provided

• Recall recorded

• Radiograph justification

• Clinical findings noted

• Quality grade noted (QA1, 2 or 3)

• Referrals recorded

• Initial

• Updated?

Medical History

Batch Numbers and Expiry Dates

AFTER THE INSPECTION:

• Immediate Assurance letter within 2 days (if necessary)

• Draft report for factual accuracy check within 3 weeks

• 3 domains:

– Quality of patient experience

– Delivery of safe and effective care

– Quality of management and leadership

• Respond to Improvement Plan within 2 weeks

• Report translated and published on HIW website 3 months after date of

inspection

• Radiation – IRR 1999 and IR(ME)R 2000

• Decontamination – WHTM01-05

• Patient records –medical histories; justification and clinical

findings from radiographs

• No mechanism for patient feedback

• No evidence of indemnity insurance

• CPR training out of date

• No hepatitis B vaccination records

• Out of date drugs/equipment

• Staff appraisals

Typical Issues

• Lack of IRMER training

• X-ray equipment lacking certification –

registration and servicing

• Ultrasonic scaler handpieces and 3-in-1 tips not

sterilised after each use. (This has arisen at 3

inspections.)

• Inappropriate PAT testing

• Medications out of date

• No CPR training records

Issues That Have Warranted the

‘Immediate Assurance’ Process

• Endodontic files being re-used

• Lack of audit (in compliance with WHTM 01-05)

• No maintenance certificates for autoclaves

(twice)

• Infection control issues

• Breach of Care Standards Act 2000 – private

practice not registered with HIW & use of class 4

laser unregistered

• Poor clinical practice (GDC?)

• Complaints procedure either not clearly

displayed or compliant with ‘Putting Things

Right’

• Patient’s views not sought e.g. by

questionnaires etc

• X-ray justification not recorded &/or quality of

images not recorded

• X-rays not reported upon

• Practices unaware of their DBS obligations

• Corporates and shared practice managers

Issues Leading to Recommendations in

Reports

• Inspection workbook is now published on the

HIW website to assist practices to prepare in

advance of inspections

• We have occasionally found disparity between

the QAS returns and the actual inspections!!

Other Comments

Thank you

Any questions or suggestions?