Policies, Procedures & Documentation

It is essential that all patients are treated in an environment in which standards are met. Every patient entering the practice should feel secure in the knowledge that they are being treated in a safe and clean environment and that the practice is working to policies and procedures to enable this.

Overview of Policies and Procedures Required

This section highlights the need for policies and procedures in a dental practice and includes a brief over view of what should be included.

It is essential that all patients are treated in an environment in which standards are met. Every patient entering the practice should feel secure in the knowledge that they are being treated in a safe and clean environment and that the practice is working to policies and procedures to enable this.

All policies should be supported by standard operating procedures to back up what is specified in the larger document.

It is necessary for a dental practice to be compliant with essential quality requirements and be able to provide evidence of this in the event of a CQC visit, and to provide instruction to staff which will enable them to work to the guidelines set out by the practice. In addition to this, staff training should also be put in place to ensure standards are met and that policies can be followed effectively. It is important to remember that many policies may overlap, but specific policies should reflect a closer insight into the relevant topic.

It is also important for the practice to provide detailed written documentation that is tailored specifically to the practice.

Below are some examples of what policies should be included in the day to running of the dental practice:

Infection Prevention and Control Policy

All practices should provide a detailed policy to ensure that they are meeting requirements in relation to the spread of health care associated infections.

This policy should include all aspects of infection control protocol needed for the day to day running of the practice, some examples being:

  • All sterilisation processes.
  • Hand hygiene.
  • Personal protective equipment.
  • Good personal hygiene.
  • Maintenance and testing of the decontamination equipment.

It is essential that every practice evidences this and can provide it in the event of a CQC visit.

HTM 01-05 provides guidelines of the requirements needed and will help construct the information needed for all policies relating to infection prevention and control, and decontamination.

Local Decontamination of Re-Usable Instruments

This policy supports anything in relation to the decontamination processes in the practice and should include any decontamination methods, management of single use items, environmental cleaning, personal protective equipment, storage and transportation of instruments.  

Hand Hygiene Policy

This policy is briefly outlined in the infection prevention and control policy but is required to provide a closer insight into the importance of good hand hygiene in the dental practice. It gives indication as to when and how to provide hand hygiene effectively.

Management of Sharps and Needle Stick Injury

Included in this policy should be detailed information on how any sharps used within the practice are managed and disposed of.

This should include details of how the operator or user is required to manage sharps in a safe manner, and should also include a section on what to do in the event of a needle stick injury.

As with all policies in place, a standard operating procedure should be available to staff on how procedures should be performed.

Environmental Cleaning Policy

This policy includes instruction for staff in relation to the general cleanliness of the dental practice environment.

It specifies information on general good practice required including roles and responsibilities of staff, how to carry out effective cleaning, cleaning schedules, and the colour coding system required to ensure this is adequate. The information as with all policies should be documented.

Policy on New and Re-Usable Dental Instruments

Included in this policy is a closer insight into how new and re-usable instruments should be processed, transported and stored.

It should be taken into consideration which method of processing is required for each instrument.

Practices using instruments that can only be processed using manual cleaning should be working towards best practice and therefore phasing this out in favour of a more robust cleaning method such as ultrasonic baths and washer disinfectors which are a validated cleaning method.

A protocol should also be implemented for any instruments that require to be dismantled prior to the decontamination process.

Personal Protective Equipment

This policy describes in detail the need for adequate personal protective equipment (PPE) and how and when it should be worn.

It is important to be aware that PPE should be fit for purpose for the  procedure to be undertaken and should provide a guideline to staff on what is appropriate to use and when.

It also gives guidance to staff of how to care for uniforms or clothing related to the working environment.

Prevention of Blood Borne Viruses Policy 

This policy aims to minimise the risk of the transmission of blood-borne viruses and should include management of sharps and needle stick injury.

It is important to highlight and document the local occupational health arrangements for your practice as protocol must be followed to ensure adequate screening takes place against blood –borne viruses such as Hepatitis B and C and HIV.

This policy should also include details of all staff immunity documents which are required prior to working in the decontamination or clinical area in the practice.

Waste Management Policy

This policy should include anything in relation to the storage and disposal of all clinical waste in the dental practice.

It should include details of handling and of who is authorised to handle waste within your practice. Documentation of the designated waste collection service is also a requirement.

A protocol should be included to document the frequency and procedures to follow when contacting the waste management company for removal of dental waste.

Management of Dental Medical Devices Policy

Details of all medical devices used throughout the patient journey should be included here.

It should specify information relating to the cleaning and maintenance of the medical devices.

Accurate documentation is required for validation, servicing, testing and maintenance of all equipment, and should specify the third party or competent person responsible for carrying this out.

Details of authorised users and operators should be included within the policy.