Primary Care Dental Services Clinical Governance Framework

Primary Care Dental Services Clinical Governance Workbook

THEME 1 – Infection Control C1, C4, C10, C20, C21, D1, D12, D13

Requirements

Procedures in accordance with BDA/DH Advice Sheet A12 (Infection Control in Dentistry) including:
· Infection control policy
· Inoculation injury policy and recording of Hepatitis B immunisation status of exposure prone staff
· Staff induction programme to include infection control procedures and staff training
· Audit of policy compliance
Information
BDA/DH advice sheet A12 (Infection Control in Dentistry)
GDC Standards for Dental Professionals 2005
BDA Practice Compendium – model policies

Compliance with A12

ID

WHO

INDICATOR

WRITTEN EVIDENCE

ASSESSMENT VISIT

1.1 /

?

/ Separate areas for reprocessing, identified clean / dirty areas in surgeries / § Training records on IC/induction
§ Completion of self-assessment IC audit tool
§ Hepatitis B immunisation status records
§ Needlestick injury policy and training records of staff / § Practice Visit
§ IC Audit Tool
1.2 /

?

/ Fully maintained and H&S compliant:
§ Ultrasonic
§ Washer and dryer
§ Autoclaves

GUIDANCE

/ · The practice self-assessment audit can be verified at practice visit.
· Assessors should be able to readily access relevant IC training records.
· Assessors should be able to access re-processing equipment maintenance and service records for past year and evidence of daily checks for previous quarter.
· All staff should maintain up to date personal development portfolios, confirming IC practice induction and training, that could be viewed by assessors during visit.
THEME 2 – Child Protection C2, C6, C10

Requirements

§ Identification and CRB checks for all staff
§ Child protection policy which is consistent with local and wider policies including any staff training requirements
Information
CRB website: www.crb.gov.uk
NHS guidance
Local Safeguarding Children Board Procedures
Child protection and the Dental Team, book and www.cpdt.org.uk due May 2006 COPDEND

ID

WHO

INDICATOR

WRITTEN EVIDENCE

ASSESSMENT VISIT

2.1 /

?

/ All staff are aware of PCT Child Protection requirements and procedures / § Child Protection policy and relevant training and induction records for all staff.
§ Comprehensive staff Human Resources records (identification, references and qualification checks) / § Practice visit
§ Self-reported
2.2 /

?

/ Practice policy on Child Protection consistent with PCT Child Protection Policy

GUIDANCE

/ § All staff should respond positively and be familiar with Child Protection procedures and policies, assessors can confirm this during practice visit by speaking to staff.
§ Induction/training records and personal CPD portfolios readily available to confirm.
§ Identity/CRB/references and qualification checks for all staff readily available in Human Resources records.
THEME 3 – Dental Radiography C1, C11, C24

Requirements

Procedures and policies in accordance with the IRR(1999) and IR(ME)R(2000) including:
§ A quality assurance system
§ X-ray malfunction plan, including how to manage an unintended over-exposure
§ Records of staff training
§ X-ray equipment maintenance records

Information

IRR 1999 and IR(ME)R 2000
BDA advice sheet A11 (radiation in dentistry)
NRPB guidance notes for dental practitioners
http://www.hpa.org.uk/radiation/publications/_misc_publications/dental_guidance_notes.pdf

WHO

INDICATOR

WRITTEN EVIDENCE

ASSESSMENT VISIT

3.1 /

?

/ All legal requirements with regard to radiological protection are satisfied / § Staff training/induction records
§ Maintenance and service records
§ Evidence of regular audits to ensure radiographs are of diagnostic value
§ Evidence of justification for radiographs and reports on finding within clinical records / § Practice visits
§ DRO reports
§ Self-reported questionnaires
§ Audit reports
3.2 /

?

/ Fully maintained and H&S compliant x-ray equipment in place
3.3 /

?

/ QA system and x-ray malfunction plan in place

GUIDANCE

/ § Assessors could confirm at practice visit that all legal requirements are met by viewing relevant documentation.
§ Assessors will have access to DRO reports and could confirm by viewing a sample of records that clinical justification for radiographs and findings are recorded in clinical records.
§ Assessors could access staff training reads on dental radiography.
THEME 4 – Staff, Patient, Public and Environmental Safety C1, C4, C5, C20, C21, D12

Requirements

· Significant events analysis procedures and changes to procedures initiated as a result
· Compliance with Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995
· Procedures to ensure all relevant safety alert bulletins are disseminated to staff and acted on
· All medical devices are CE compliant, staff training for usage provided and incident reporting carried out
· Medicines are appropriately sourced, purchased and stored including a medical emergencies drug kit
· Compliance with Carriage of Dangerous Goods and Use of Transferable Pressure Equipment (Amendment) Regulations 2005
· Hazardous waste regulations 2005 and the management of waste amalgam/mercury
· Health and Safety at Work Act 1974
· Management of Health and Safety at Work Regulations 1999
· Workplace (Health, Safety and Welfare) Regulations 1992
· Control of Substances Hazardous to Health Regulations 2002
· (Also see Infection Control, Child Protection and Dental Radiography)

Information

Seven Steps to patient Safety – NPSA:
www.npsa.nhs.uk/sevenstepsBDA Advice Note 53 (amalgam separators)
RIDDOR Regulations 1995
Health and Safety (First Aid) Regulations 1981
MHRA safety notices (bulletins are posted on BDA website: www.bda-dentistry.org.uk)
MHRA Regulations
DPF/BDA advice sheet B9 (Prescribing in general practice)
GDC guidelines
Medicines Control Agency (MCA)
Health and Safety at Work Act 1974
BDA Advice sheet A3 (Health & Safety law for dental practice)
CoSHH Regulations 2002
BDA Advice sheet A5 (Risk assessment in dentistry)
Management of Health and Safety at Work Regulations 1999
BDA Advice sheet D14 (Violence at Work)
Carriage of Dangerous Goods and Use of Transportable Pressure Equipment (Amendment) Regulations 2005

WHO

INDICATOR

WRITTEN EVIDENCE

ASSESSMENT VISIT

4.1 /

?

/ Practice meets all legal requirements for staff, patients, public and employee safety / § Significant event and incidence reporting policy and reports.
§ Practice policy and procedures in place for RIDDOR safety bulletins and medical devices, hazardous waste, and use of pressure equipment, invoices and stock rotation records. / § Incident reports
§ Practice Visit
4.2 /

?

/ All relevant H&S notices are displayed
4.3 /

?

/ All medicines and products used in clinical care are appropriately sourced, purchased and stored

GUIDANCE

/ § The practice should report significant event incidents in a consistent format
a) Statement of problem or event/learning outcomes and action plan; or
b) What happened? Why did it happen? Was insight demonstrated? Was change implemented?
§ The practice should involve team members and PCT if appropriate.
§ Assessors could confirm practice policies and procedures and relevant documentation in place for RIDDOR safety bulletins and medical devices, hazardous waste, use of pressure equipment, and confirm that staff are familiar with and compliant with procedures and policies.
§ Assessors could confirm all medicines and clinical products are in date, stored appropriately and that all staff are aware and compliant with requirements.
THEME 5 – Evidence based Practice and Research

Requirements

§ Relevant NICE Guidelines are followed
§ Clinical care is informed by other evidence-based guidelines
§ Existing care pathways and referral protocols are followed
§ Where appropriate, principles of research governance are applied

Information

NICE guidance[1][2]
Faculty of Dental Surgery guidance
http://www.rcseng.ac.uk/fds/docs
Scottish Intercollegiate Guidance Network
http:/www.sign.ac.uk/guidelines/pubishesd/index.html
Local referral protocols (where exist)
Local research ethics committees

WHO

INDICATOR

WRITTEN EVIDENCE

ASSESSMENT VISIT

5.1 /

?

/ NICE guidelines are followed / § Clinical records justify recall intervals
§ Resources to assist patients contribute to and understand decisions on recall intervals.
§ CPD portfolios for all clinical include updates on evidence-based guidelines are implemented / § Clinical records/DRO reports
§ Practice Visit
§ BSA on-line interrogation
5.2 /

/ Clinical staff are aware of and implement evidence-based guidelines

GUIDANCE

/ § Assessors can confirm compliance with NICE guidance recall intervals by surveying clinical records.
§ Clinical treatment plans reflect implementation of evidence-based guidance, e.g. child with active decay receives advice, exposure to fluoride and restorative care as appropriate and consistent with evidence-based approach.
§ Compliance with referral protocols for e.g. IOTN and local referral protocols for dental specialties as they develop
THEME 6 – Prevention and Public Health C22, C23, D13

Requirements

An evidence-based prevention policy for all oral diseases and conditions appropriate to the needs of the local population and consistent with local and national priorities. This should include:
· Links to any existing community based strategies
· Tobacco use cessation
· Alcohol consumption advice
(Also see Infection Control, Patient, Public and Environmental Safety)

Information

BDA/NHS/HAD: Helping smokers stop: A guide for the dental team (2004). Available at www.publichealth.nice.org.uk/page.aspx?o=502735
Scientific Basis of Oral Health Education (Levine and Stillman-Lowe, 2004)
National/local oral health strategy www.dh.gov.uk/assetRoot/04/12/32/53/04123253.pdf

WHO

INDICATOR

WRITTEN EVIDENCE

ASSESSMENT VISIT

6.1 /

/ All staff aware of PCT’s oral health needs assessment and evidence based prevention policy outlined in Choosing Better Oral Health / § Comprehensive preventive advice given and recorded in clinical records and consistent with wider public health messages
§ Smoking status recorded in 75% of clinical records
§ Records from practice based smoking cessation services. / § Practice Visit
§ Referrals to smoking cessation service
6.2 /

/ Evidence-based policy resources and preventive measures are readily accessible and utilised in the practice

GUIDANCE

/ § All staff aware of preventive policy and key public health messages appropriate to the needs of PCT population
§ Assessors can confirm that appropriate, consistent advice and preventive care is given and recorded in clinical records
§ Assessors can confirm smoking status is recorded in clinical records and referral information is given as appropriate.
THEME 7 – Clinical records, patient privacy and confidentiality C9, C13, C20

Requirements

· Staff awareness of and compliance with Data Protection Act 1998
· Caldicott Guidelines 1997, Access to Health Records 1998 and Confidentiality Code of Practice 1998 are followed
· Confidentiality policy satisfactory arrangements for confidential discussions with patients
· Data protection policy

Information

Clinical Examination and Good Record Keeping: Good Practice Guidelines, FGDP
GDC Standards for Dental Professionals 2005
Professional indemnity insurers advice (DDU, DPS, MDDUS)
BDA Advice Sheet B2 (Data protection)
Data Protection Act 1998
Caldicott guidelines 1997
www.informationcommissioner.gov.uk
Records Management: NHS code of practice
www.nhsia.nhs.uk/infogov/igt

WHO

INDICATOR

WRITTEN EVIDENCE

ASSESSMENT VISIT

7.1 /

/ Practice complies with all relevant legislation / § Confidentiality policy in place and training records confirm
§ Satisfactory DRO reports on clinical record keeping
§ Clinical audit reports / § Practice visits
§ PALS/Complaints
7.2 /

/ Staff are familiar with and adhere to policy and guidelines
7.3 /

/ Patient privacy and confidentiality is respected
7.4 /

/ Clinical records are stored and completed appropriately

GUIDANCE

/ § Assessors could confirm all clinical records are securely stored in a lockable filing system.
§ Assessors could confirm that patient privacy and confidentiality is maintained in all practice settings by all practice staff in line with guidance
THEME 8 – Staff Involvement and Development (for all staff) C5, C8, C10, C11, C21, C24, D7, D12

Requirements

· Employment policies – appropriate job descriptions for all posts
· Appraisal, personal development plans and links to mentoring schemes
· Appropriate staff training undertaken and records of staff training maintained (e.g.customer training, equal opportunities, dealing with complaints and patient feedback)
· Records of practice meetings and evidence of staff involvement
· Protected time for staff meetings and clinical governance
· Confidential process for staff to raise concerns about performance
· Links to a local Practitioner Advice and Support Scheme (Pass) or similar
· Evidence of regular basic life support training
· Evidence that staff opinion is sought about practice matters (e.g. staff surveys, practice meetings)

Information

GDC – Standards for Dental Professionals 2005
NHS(GDS) Complain6ts Regulations 2004
BDA Advice sheet B10 (Handling Complaints)
http://www.nhs.uk/England/AboutTheNhs/ComplainCompliment.cmsx
BDA Advice sheet E10 (CPD, clinical governance, audit and peer review)
Postgraduate Dental Office
Personal Development Plans for Dentists (Amar Rughani et al)
CPD – A guide for the Dental Team (BDA)
BDA advice sheet D12 (staff recruitment) www.investorsinpeople.co.uk
BDA Advice sheet D13 (Discrimination)
Equal Opportunities Commission www.eoc.org.uk

WHO

INDICATOR

WRITTEN EVIDENCE

ASSESSMENT VISIT

8.1 /

/ The practice has a written procedure manual that includes staff employment policies including equal opportunities, bullying and harassment, sickness and absence, to which staff have access / § Employment procedure manual available
§ Comprehensive HR and Training records for all staff includes up-to-date job description and mandatory training record, i.e. BLS
§ Personal portfolios include evidence of appraisal and objective setting
§ Minutes of regular practice meetings and staff feedback
§ Policy on raising concerns at work with identified links to PASS / § Practice visits
§ Self-assessment
§ Occupational health and PASS referrals
8.2 /

/ The practice has up-to-date comprehensive HR and training records for all staff
8.3 /

/ Practice holds well attended meetings where all staff contribute
8.4 /

/ Practice protects for clinical governance
8.5 /

/ Practice team regularly test collapse procedure against clock

GUIDANCE

/ § The procedures manual should contain dated copies, which are made available to staff of the policies relating to their employment.
§ Assessors should confirm with employed staff that they are aware of the content of the manual and its whereabouts
THEME 9 – Clinical staff Requirements and Developments C4, C5, C10, C11

Requirements

(Items listed under Staff Involvement and Development also apply)
All GDC requirements are met including:
· GDC registration/enrolment where appropriate
· Supervision of clinical staff
· Continuing Professional Development requirements
· Handling of complaints
Dealing with poor performance (including “whistle blowing” policy)

Information