1. Purpose
This policy sets out how the Practice decontaminates reusable dental instruments, records traceability, checks equipment and audits the process. It is written for primary-care dental services that use local decontamination arrangements.
This policy is a starting template. The Practice must verify the detail against the current Health Technical Memorandum 01-05 source before adoption.
2. Sources to verify before adoption
- NHS England, Health Technical Memorandum 01-05: Decontamination in primary care dental practices: https://www.england.nhs.uk/publication/decontamination-in-primary-care-dental-practices-htm-01-05/
- HTM 01-05 PDF, 2013 edition: https://www.england.nhs.uk/wp-content/uploads/2021/05/HTM_01-05_2013.pdf
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12: https://www.legislation.gov.uk/uksi/2014/2936/regulation/12
- CQC dental guidance and current assessment material for infection prevention and control: https://www.cqc.org.uk/guidance-providers/dentists
3. Scope
This policy applies to:
- all reusable dental instruments used at the Practice
- all clinical staff who handle, transport, clean, inspect, sterilise, store or trace instruments
- the decontamination room, clean storage areas and any surgery-level transfer process
- validation, maintenance and testing of washer-disinfectors, ultrasonic cleaners and sterilisers where used
Single-use instruments are not reprocessed. Staff dispose of them according to the Practice waste policy.
4. Decontamination cycle
The Practice follows a documented decontamination cycle for each reusable instrument batch.
4.1 Acquisition and intake
- The Practice buys instruments from approved suppliers and records the instrument type, batch or asset reference where available.
- The Practice checks new instruments before first use and records that they are suitable for the intended dental procedure.
- Damaged, corroded or unsuitable instruments are removed from use.
4.2 Transport from surgery to decontamination area
- Used instruments are moved in a designated lidded container.
- Staff keep used instruments separate from clean instruments at all times.
- Sharps are managed under the Practice sharps policy.
4.3 Cleaning
- Staff clean instruments using the Practice-approved process, such as washer-disinfector, ultrasonic cleaner or manual cleaning where permitted by the local procedure.
- Staff follow the equipment manufacturer's instructions and the current HTM 01-05 source for the chosen cleaning route.
- Staff record failed cleaning cycles and repeat the process before inspection.
4.4 Inspection
- Staff inspect instruments under adequate lighting before sterilisation.
- Any instrument that remains visibly contaminated, damaged or unsafe is removed from the clean flow.
- The staff member records rejected instruments and the action taken.
4.5 Sterilisation
- Staff sterilise instruments only in a validated steriliser.
- Staff select the cycle that matches the instrument and packaging status.
- Staff record the cycle reference, date, time, operator and any failed cycle.
4.6 Storage
- Staff store sterile or disinfected instruments in the designated clean area.
- Packaged instruments are stored according to the current HTM 01-05 source and local procedure.
- Staff do not use instruments where packaging is damaged, wet, unsealed or past the Practice's locally verified storage period.
4.7 Traceability
- The Practice keeps instrument traceability records that connect the instrument batch, sterilisation cycle and patient record where the Practice's process requires it.
- Traceability records are kept in the decontamination log or approved digital record.
- Where traceability cannot be confirmed, the Registered Manager reviews whether the instruments can be used.
5. Essential-quality and best-practice-quality position
HTM 01-05 distinguishes between essential-quality requirements and best-practice-quality improvements. The Practice records its current position against both levels.
- Essential quality: the Practice must meet the essential-quality decontamination standard before this policy is adopted.
- Best-practice quality: the Practice keeps a written improvement plan for any best-practice-quality element not yet in place.
- The Registered Manager reviews the position at least annually and after any equipment, premises or process change.
The Practice must verify the current wording and test requirements in HTM 01-05 before adopting this section.
6. Autoclave validation and equipment checks
The Practice keeps an equipment file for each steriliser. The file includes:
- asset number and location
- manufacturer and model
- installation date
- planned preventive maintenance record
- validation record
- daily, weekly, quarterly and annual test records where the current HTM 01-05 source requires them
- fault reports and service engineer reports
Staff do not restate test frequencies from memory. They use the current HTM 01-05 source and the manufacturer's instructions when setting the local test schedule.
7. Responsibilities
- Registered Manager: owns this policy, ensures the Practice has suitable premises, equipment, training and audit arrangements, and signs off annual review.
- Decontamination lead: maintains the local procedure, equipment files, validation records, decontamination logs and audit schedule.
- Dentists and dental therapists: ensure instruments used in treatment have passed through the approved decontamination cycle and report any contamination or traceability concern.
- Dental nurses: carry out the decontamination cycle only after training and competency sign-off. They record cycles, checks and rejected instruments.
- All clinical staff: keep dirty and clean flows separate, follow standard infection prevention precautions and report faults immediately.
8. Recording requirements
The Practice keeps the following records:
- decontamination cycle logs
- steriliser cycle records
- failed cycle records and corrective action
- validation, maintenance and service records
- instrument rejection records
- traceability records where required by the local process
- staff training and competency records
- daily, weekly and annual audit records, with the exact check list verified against the current HTM 01-05 source
Records are kept in the Practice's governance records and are available for internal audit, CQC review and external review where required.
9. Audit cadence
The Practice uses the following Verivius default audit rhythm unless the current HTM 01-05 source, commissioning requirement or local risk assessment requires more frequent review:
- Daily: staff complete the local decontamination process checks and record failed cycles or rejected instruments.
- Weekly: the decontamination lead reviews logs for missing entries, failed cycles, equipment faults and traceability gaps.
- Monthly: the Registered Manager or delegated clinical lead reviews a sample of instrument journeys from surgery to storage.
- Annually: the Practice completes a full decontamination audit against HTM 01-05 and updates the improvement plan.
Any audit finding is recorded as an improvement action with an owner and review date.
10. Version control and review date
The Practice keeps a controlled copy of this policy. The footer or document-control table records:
- policy owner
- version number
- date approved
- next review date
- changes made since the last version
- source material checked during the review
11. Related records
- Infection prevention and control audit
- Premises and equipment policy
- Sharps policy
- Waste-management policy
- Staff training matrix
- Equipment maintenance file
- Decontamination log
Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.