Our A-E (Decontamination) Service
Decontamination control is vital in preventing the spread of disease. We will adapt our A-E audit to cover the following Health Technical Memorandums:
HTM 01-01: Management and decontamination of surgical instruments (medical devices) used in acute care
HTM 01-04: Decontamination of linen for health and social care
HTM 01-05: Decontamination in primary care dental practices
HTM 01-06: Decontamination of flexible endoscopes.
Our scope will be to assess those responsible for the various aspects of the decontamination management process. We will also assess that the appropriate documents and records are available and that they have been suitably controlled.
HTM 01-01: We will assess the responsibilities and processes for the control of contamination on surgical instruments. Traditionally, cleaning validation of such instruments has been about removing visible soiling. Now the emphasis is on removing adherent proteins o these instruments. Areas of consideration will include:
• Validation and verification methods for washer disinfectors.
• Test programmes
• Specification for water supplies
• Operational management
HTM 01-04: We will check that laundry equipment is fit for use and appropriately certificated. We will check documentation relating to the laundry equipment, including the names of key personnel period. We will also assess periodic testing and maintenance procedures and records. We will also assess the appointment and training of operators where required.
HTM 01-05: Where appropriate, we will assess the procedures and responsibilities for the decontamination of dental instruments and equipment.
HTM 01-06: We will assess the procedures and responsibilities in the assurance that endoscopy equipment remain decontaminated. We will focus on issues such as the washing and cleaning process, and how the process ensures minimal time delays from patient use to the decontamination process. We will advise on the cleaning efficacy of endoscope washer disinfectors.
Our annual authorising-engineer audit addresses the key issues relevant to maintaining compliance with the management systems covered by HTM 01. The scope and methodology of the audit are given below:
Documentation review: We will undertake a full offsite (or onsite if necessary) assessment of all your relevant decontamination documentation, procedures and processes.
Onsite assessment: We will attend every site covered by the scope of the scheme and assess the following:
An assessment of the use of the documents previously reviewed with the relevant Trust fire teams.
Undertaking a procedural assessment of document use to ensure an effective audit trail.
Interviews with relevant staff and other third parties to assess their understanding of their responsibilities.
A record of our findings which will be included within our executive report.
Report Preparation: We will prepare a specially formatted "AdashE" report designed for the Trust Executive. This will include all our findings within a single Trust Report (where multiple sites are involved). The report will include a prioritised action plan.
Presentation of Results: We will arrange an onsite presentation to Trust representatives to formally give our findings together with suggestions. This will also include a question and answer session.
Our annual workshop will be held in one or more parts of the country and will address a number of key and topical issues of interest to those making use of authorising-engineer services. The workshop will be developed in line with the development of the scheme.
Our post audit service is offered after a CQC audit where issues require urgent follow up. Up to two resource days per year are included in the scheme and is based on our offsite attendance which may include liaison with the auditing personnel. If onsite attendance is required, this will be charged for separately.
Our technical support service can be accessed via this website using the members portal. We will aim to respond within 48 hours. If onsite attendance is required, this will be charged for separately.