TRAINING PRACTICE MONITORING FORM
Centre Details:
Name London Waterloo Academy
Address 103-107 Waterloo Road. London SE1 8UL
E-mail [email protected]
Telephone 02079288995
Tutor Details:
Name
GDC registration number
Student details:
Name
Practice address
Telephone
Employer Details:
Name
GDC registration number
Workplace mentor details:
Name
GDC registration number
Induction completed by training provider (please give details of date and location)
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Practice Details:
Type e.g. GDP, Private, Hospital, Specialist.
Evidence of certification e.g. CQC and PCT are required.
Voluntary certification, e.g. BDA Good Practice, Denplan etc.
Please give full details including dates!
Please give details of practice induction of the student e.g. CRB checks,
vaccination record, health and safety, ionising radiation and infection
control.
Number of Qualified staff and their role and responsibilities and GDC
registration details:
Name Role and responsibilities GDC Number
2
Please tick all relevant boxes where your student dental nurse will have
appropriate access to the procedures described below:
Preparing the Clinical Environment
Maintaining the Clinical Environment
Sterilisation Process
Disinfection of impressions
Assisting with Preventative Treatment
Assisting in the taking and processing of radiographs
Cavity Restoration Procedure
Endodontic Procedure
Fixed Prostheses Procedure
Removable Prostheses Procedure
Extraction Procedure
Local Anaesthesia Procedure
Information on workplace arrangements to overcome foreseen problems in
regard to the completion of the record of experience competencies:
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HEALTH AND SAFETY (Health and Safety at Work etc. Act 1974).
Poster: Is there a poster on display from the Health and Safety Executive? HSE
Poster:
Yes No
Policy: Is there a recently updated written safety policy for the practice on display
or accessible to all staff?
Yes No
RISK ASSESSMENT:
Has a risk assessment been carried out to identify the hazards within the
practice?
Yes No
Have the risks been assessed? Yes No
Have assessments been made of all the substances used within the practice to
identify which might be hazardous to health?
Yes No
Have the risks been assessed?
Yes No
Are records of these assessments available?
Yes No
Specific risk assessment is required for young persons and new and expectant
mothers (preferably in writing).
Yes No
WELFARE:
Have you provided adequate facilities and arrangements for staff welfare
Yes No
FIRE:
Is there adequate fire fighting equipment and means of fire detection throughout
the practice and are staff trained to deal with such situations?
Yes No
Is there a fire escape and is it adequately signposted?
Yes No
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Are passages free from obstruction?
Yes No
Are fire extinguishers regularly inspected and serviced?
Yes No
PUBLIC LIABILITY:
Do you have adequate public liability insurance to cover your premises?
Yes No
Is a certificate displayed? Yes No
EMPLOYER’S LIABILITY:
Have you on display a current employer’s liability insurance certificate?
Yes No
FIRST AID:
Is there adequate first aid provision? Yes No
Has a suitable person been appointed to give first aid and is this information
displayed?
Yes No
ACCIDENTS/RIDDOR:
Is there an accident report book available and maintained?
Yes No
Are there systems in place for reporting relevant incidents to the HSE?
Yes No
WASTE DISPOSAL:
Is waste segregated into hazardous and non-hazardous and stored safely prior to
disposal?
Yes No
Are there arrangements for the collection and disposal of these wastes?
Yes No
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Are copies of the transfer notes and consignment notes available?
Yes No
MERCURY:
Is there a mercury spillage kit? Yes No
Are staff aware of the procedure to deal with mercury spillage?
Yes No
Is there proper storage (and disposal – is encapsulated amalgam used?) of
metallic mercury and waste mercury material?
Yes No
AUTOCLAVE:
Is there an inspection certificate? Yes No
Is the autoclave maintained and tested
Yes No , According to HTM 01-05?
COMPRESSORS:
Is there an inspection certificate? Yes No
Is there a service/maintenance contract in place? Regulations 2000, SI 2000 No
128, ISBN 0 11 085836 0; Provision and Use
Yes No
GAS CYLINDERS:
Are they properly stored? Are the cylinders regularly serviced? Are records of
servicing available?
Yes No
ELECTRICAL APPLIANCES:
Are regular visual inspections of all portable equipment carried out?
Yes No
Are records available? Yes No
Are all portable electrical equipment and the fixed supply inspected and tested at
least every three to five years by a competent person?
Yes No
Are records available? Yes No
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RADIATION:
Have you informed the Health and Safety Executive of your x-ray machines?
Yes No
Have you appointed a radiation protection adviser? Yes No
Is there documentation of regular radiation safety assessment of all radiographic
equipment?
Yes No
Are there local rules on display? Yes No
Are all staff using x-ray equipment adequately train
ed and records of training kept? Yes No
Is the quality of radiographic processing and radiographic images continually
assessed?
Yes No
COMPUTERS & DISPLAY SCREEN EQUIPMENT:
If you use a computer, are you registered with the Office of Data Protection?
Yes No
Do you comply with the Health and Safety (Display Screen Equipment)
Regulations 1992?
Yes No
Has an assessment of the workstation been carried out?
Yes No
Have employees using DSE regularly been offered eye and eyesight tests?
Yes No
Data Protection Act 1998; 90/270/EEC; Health and Safety (Display Screen
Equipment) Regulations 1992; Display screen equipment work – guidance on
regulations ISBN 0 11 886331 2.
Yes No
DRUGS:
Do you have the emergency drugs recommended for dentists by the British
Resuscitation Council?
Yes No
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Are emergency drugs kept securely, but accessible at all times?
Yes No
Are strict records kept of the purchase and dispensing of drugs?
Yes No
Are drugs stored according to manufacturers’ recommendations and kept in a
locked cupboard?
Yes No
LABORATORY:
If there is a laboratory on the premises has an assessment been made under the
Factories Act and other special legal requirements?
Yes No
Is the Laboratory registered with MHRA? Yes No
EMERGENCIES:
Does the practice record and regularly update patient medical history?
Yes No
Is there a pocket mask? Yes No
Is there an up-to-date emergency drugs kit? Yes No
Is there an oxygen kit? Yes No
Are staff trained regularly in resuscitation? (Date____________) Yes No
If your practice undertakes inhalation or intravenous sedation, does your practice
conform to the current recommendations?
Yes No
Is there a first aid kit and is there a qualified first-aider or appointed person to
give first aid?
Yes No
INFECTION CONTROL:
Are staff trained in infection control? (Date _____________) Yes No
Are staff vaccinated against Hepatitis B and the other common illnesses;
diphtheria, pertussis, poliomyelitis, rubella, tetanus, TB?
Yes No
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Are reports available indicating responses to the Hepatitis B vaccine and when
boosters are due?
Yes No
Is there an autoclave? (Make/Model __________________________)
Yes No
Is the autoclave regularly serviced and tested? (Date _____________)
Yes No
Is there an ultrasonic bath/washer disinfector?
Yes No
Are all non-disposable clinical instruments, including burs and handpieces,
sterilised after use?
Yes No
Are clinical items sent to others (e.g. impressions to the laboratory) properly
treated for cross-infection control?
Yes No
Do members of the practice either dispose of or sterilise between patients the
following items:
aspirator tips? Dispose Sterilise
impression trays? Dispose Sterilise
Do members of the practice use disposable:
paper towels? Yes No
surgical blades? Yes No
local anaesthetic cartridges? Yes No
needles? Yes No
gloves? Yes No
facemasks? Yes No
mouthwash cups? Yes No
Is eye protection provided & used by staff and patients?
Yes No
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Is there appropriate and adequate ventilation of the premises, especially
treatment rooms, sterilising rooms, storage areas and developing areas?
Yes No
Does the practice comply with the “essential” requirements of HTM 01-05?
Yes No
FACILITIES FOR THE TRAINEE NURSE
Is there regular provision for a workplace mentor? Yes No
Is there a reasonable practice library? Yes No
Is there a computer with broadband access that the trainee nurse can easily
access?
Yes No
DOCUMENTATION
Are copies of the following documentation available for inspection or on display:
Health and Safety poster?
Yes No
Practice policy on health and safety? Yes No
Autoclave maintenance and inspection? Yes No
Compressor maintenance and inspection? Yes No
Fire equipment maintenance? Yes No
Records relating to safety checks on:
(i) portable electrical equipment? Yes No
(ii) the fixed electrical supply? (NICEIC Test Certificate) Yes No
Data protection registration (if applicable)? Yes No
Computer software licence (if applicable)? Yes No
Employer’s liability insurance certificate? Yes No
Current Certificate of professional indemnity? Expiry Date…………….
Yes No
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GDC annual practising certificate? Yes No
Risk assessment and COSHH assessments? Yes No
Clinical waste transfer contract (for sharps and other clinical waste) Provider
……………………. Yes No
Transfer Note for period …………………………….. Yes No
Hazardous waste disposal contract? Provide……………………………...
Yes No
Transfer Note for period…………………………… Yes No
Records relating to radiation safety assessment of all radiographic equipment?
Yes No
Details/Location of
X-Ray Machine
………………………
………………………
………………………
Date of Safety Assessment
………………………
………………………
………………………
Details/Location of X-Ray Machine
………………………
………………………
………………………
Date of Safety Assessment
………………………
………………………
………………………
Local rules for radiographic equipment? Yes No
Records of quality assessment systems for radiographs? Yes No
Registration with the Care Quality Commission? Yes No
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PLEASE READ THE FOLLOWING STATEMENTS BEFORE SIGNING THIS
FORM
(In the case of joint applicants, both must sign this form)
1. I/we have read both parts of the form and have completed the sections to the
best of my/our knowledge.
Name ………………………………………………
Signature …………………………………………………………
GDC……………….
Name…………………………………………………
Signature…………………………………………………………
GDC…………….
2. I/we agree to a practice inspection, if appropriate, and will make
approximately one hour available to the visitors.
Name ………………………………………………
Signature …………………………………………………………
GDC……………….
Name…………………………………………………
Signature…………………………………………………………
GDC…………….
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