Primary Care Dental Services Clinical Governance Workbook

THEME 1 – Infection Control C1, C4, C10, C20, C21, D1, D12, D13Requirements 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

InformationBDA/DH advice sheet A12 (Infection Control in Dentistry)GDC Standards for Dental Professionals 2005BDA Practice Compendium – model policiesCompliance 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.

NHS PCC - Primary Care Dental Services Clinical Governance Workbook

THEME 2 – Child Protection C2, C6, C10Requirements

Identification and CRB checks for all staff Child protection policy which is consistent with local and wider policies including any staff training requirements

InformationCRB website: www.crb.gov.ukNHS guidanceLocal Safeguarding Children Board ProceduresChild 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.

NHS PCC - Primary Care Dental Services Clinical Governance Workbook

THEME 3 – Dental Radiography C1, C11, C24RequirementsProcedures 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

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

ID 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 reports3.2 ?

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.

NHS PCC - Primary Care Dental Services Clinical Governance Workbook

THEME 4 – Staff, Patient, Public and Environmental Safety C1, C4, C5, C20, C21, D12Requirements

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)

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

ID 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

Incident reports Practice Visit

4.2 ? All relevant H&S notices are displayed

NHS PCC - Primary Care Dental Services Clinical Governance Workbook

and medical devices, hazardous waste, and use of pressure equipment, invoices and stock rotation records.

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 formata) Statement of problem or event/learning outcomes and action plan; orb) 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.

NHS PCC - Primary Care Dental Services Clinical Governance Workbook

THEME 5 – Evidence based Practice and ResearchRequirements

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

InformationNICE guidance12

Faculty of Dental Surgery guidancehttp://www.rcseng.ac.uk/fds/docsScottish Intercollegiate Guidance Networkhttp:/www.sign.ac.uk/guidelines/pubishesd/index.htmlLocal referral protocols (where exist)Local research ethics committees

ID 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

1 Guidance for third molars: http://www.nice.org.uk/page.aspx?o=380402 Guidance for recall intervals: http://www.nice.org.uk/page.aspx?o=225866

NHS PCC - Primary Care Dental Services Clinical Governance Workbook

THEME 6 – Prevention and Public Health C22, C23, D13RequirementsAn 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)InformationBDA/NHS/HAD: Helping smokers stop: A guide for the dental team (2004). Available at www.publichealth.nice.org.uk/page.aspx?o=502735Scientific 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

ID 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.

NHS PCC - Primary Care Dental Services Clinical Governance Workbook

THEME 7 – Clinical records, patient privacy and confidentiality C9, C13, C20Requirements

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

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

ID 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

NHS PCC - Primary Care Dental Services Clinical Governance Workbook

THEME 8 – Staff Involvement and Development (for all staff) C5, C8, C10, C11, C21, C24, D7, D12Requirements

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)

InformationGDC – Standards for Dental Professionals 2005NHS(GDS) Complain6ts Regulations 2004BDA Advice sheet B10 (Handling Complaints)http://www.nhs.uk/England/AboutTheNhs/ComplainCompliment.cmsxBDA Advice sheet E10 (CPD, clinical governance, audit and peer review)Postgraduate Dental OfficePersonal 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.ukBDA Advice sheet D13 (Discrimination)Equal Opportunities Commission www.eoc.org.uk

ID 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

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

NHS PCC - Primary Care Dental Services Clinical Governance Workbook

Policy on raising concerns at work with identified links to PASS

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

NHS PCC - Primary Care Dental Services Clinical Governance Workbook

THEME 9 – Clinical staff Requirements and Developments C4, C5, C10, C11Requirements(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)InformationGDC – Standards for Dental Professionals 2005Principles of Patient Consent 2005BDA Advice sheet B10 (Handling Complaints) http://www.nhs.uk/England/AboutTheNhs/ComplainCompliement.cmsx

ID WHO INDICATOR WRITTEN EVIDENCE ASSESSMENT VISIT

9.1 ?All staff appropriately qualified and registered

GDC registration/enrolment and qualification records are held for all staff in comprehensive Human Resources record

Up-to-date CPD portfolio in place for all staff

Complaint policy/procedures in place.

Reports available demonstrating how learning outcomes have effected change

Policy on raising concerns at work in place

Practice visit DRO reports PALS/complaints PASS9.2 ?

Practice supports appropriate CPD for all staff

9.3 ?Any learning outcomes for complaints effect change

9.4 ?

No poor performance is un-addressed

GUIDANCE Assessors could access Human Resources records and CPD portfolios Complaints procedures and reports readily available Assessor could confirm staff aware of raising concerns policy and procedure

NHS PCC - Primary Care Dental Services Clinical Governance Workbook

THEME 10 – Patient Information and Involvement C3, C7, C13, C14, C16, C17, C18, C19, C21, D2, D3, D5, D8, D9, D10Requirements

Patients’ and carers’ views on services are sought and acted upon Patients have opportunities to ask questions and provided with sufficient information to make informed decisions about their care Patient information leaflets are available in languages appropriate to the local population Well-publicised complaints system that is supportive of patients Other patient feedback methods are available (e.g. suggestion boxes) Evidence that practice have acted on findings of patient feedback Information for patients on how to access NHS care in and out of hours

InformationGDC – Standards for Dental Professionals 2005GDC – Principles of Patient Consent 2005Local patient and public involvement (PPI) strategy (where exist)BDA Practice CompendiumBDA Clinical Governance toolkitGDS/PDS Regulations draft 2006-06-15 BDA Advice Sheet B10 Handling Complaintshttp://www.dh.gov.uk/PolicyAndGuidance/OrganisationPolicy/ComplaintsPolicy/fs/enhttp://www.nhs.uk/England/AboutTheNhs/ComplainCompliment.cmsxBDA advice sheets B1 (Ethics in dentistry)BDA advice sheet A6 (Marketing in dentistry)PCT access action plans and NHS DirectNational Clinical Governance support team website:www.cgsupport.nhs.uk

ID WHO INDICATOR WRITTEN EVIDENCE ASSESSMENT VISIT

10.1 ?Patient aware of how to make comments or complaints through a number of options

Practice information leaflet Reports of patient satisfaction Surveys available and reports on

changes implemented Patient treatment plans and

consents available Resources available to inform

treatment choices

Practice PPI – mystery ‘patient’ shopper PALS/complaints

10.2 ?

Practice leaflet freely available

GUIDANCE Assessors could check practice leaflet against requirements as set out in Schedule 3 of the dental contract Assessors could check treatment plans, consents and resources available to explain different treatment options and

procedures, e.g. photographs, models

NHS PCC - Primary Care Dental Services Clinical Governance Workbook

THEME 11 – Fair and Accessible Care C7, C13, C18, C19, C21, D11Requirements(Items listed under Patient Information and Involvement may also apply)

Compliance with the Race Relations (Amendment) Act 2000 and Human Rights Act 1998 Access to interpreting services All reasonable efforts made to comply with the Disability Discrimination Act 1995

Emergency/urgent appointments available during the dayInformationwww.homeoffice.gov.uk BDA Practice CompendiumBDA Advice Sheet D13 (Discrimination)www.disability.gov.ukDDA information at pack@meads.ltd.co.ukDisability Rights CommissionRoyal Association for disability and rehabilitationLocal PCT serviceswww.languageline.co.ukEqual Opportunities Commissionwww.oc.org.uk

ID WHO INDICATOR WRITTEN EVIDENCE ASSESSMENT VISIT

11.1 ?Active engagement with PCT to support PCT to address inequalities in access to NHS dental care

DDA audit and report of reasonable changes implemented

Day book illustrates emergency slots

Contact details of interpreting service available and how to access known by staff

Practice Visit PPI/PALS mystery ‘patient’

shopper PALS/complaints Interrogation of BSA data11.2 ?

No patient refused treatment for any reason detailed in Clause 28 of the dental contract

11.3 ?Reasonable effort to meet DDA compliance

GUIDANCE Assessors could confirm booking/acceptance procedures with reception staff against contract requirements Assessors could view day sheets/appointment books for previous quarter

NHS PCC - Primary Care Dental Services Clinical Governance Workbook

THEME 12 – Clinical Audit and Peer Review C5, D1, D3, D4, D5Requirements

All staff involved in identifying priorities for and involved in clinical audit or peer review Evidence of compliance with any locally agreed requirements for clinical audit or peer review Evidence that changes have been made where necessary, as a result of clinical audit or peer review

InformationLocal audit/peer review panel or other local arrangementDental Practice Advisor (DPA)/PCT Tutor/Audit FacilitatorPostgraduate Dental Office

ID WHO INDICATOR WRITTEN EVIDENCE ASSESSMENT VISIT

12.1 ?

Practice protects time for clinical audit and learning outcomes are communicated to all staff and PCT together with improvements implemented as a result

Clinical audit reports and documented learning outcomes

Minutes of Peer Review meetings CPD portfolio

Practice Visit Copies of audit reports

submitted to PCT

GUIDANCE Assessors could confirm that documented learning outcomes reported to PCT as a result of clinical audit have been

implemented through survey of clinical records or observing procedures against reports available.

NHS PCC - Primary Care Dental Services Clinical Governance Workbook