Purpose
This annual statement will be generated annually in accordance with the requirements of The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance. It summarises:
- Any infection transmission incidents and any action taken (these will have been reported in accordance with our significant event procedure)
- Details of any infection control audits undertaken, and actions undertaken
- Details of any risk assessments undertaken for prevention and control of infection
- Details of staff training
- Any review and update of policies, procedures, and guidelines
Infection prevention and control (IPC) lead
St Mary’s Surgery has 1 Lead for infection prevention and control: Elisa Owen, Lead Practice Nurse.
The IPC Lead is supported by: Kim Schesselman
As IPC Lead, Elisa Owen attends an annual training course. Keeping updated on Infection Prevention Practice by attending the IPC update meetings every other month.
Infection transmission incidents (significant events)
Significant events (which may involve examples of good practice as well as challenging events) are investigated in detail to see what can be learnt and to indicate changes that might lead to future improvements.
All significant events are reviewed in the monthly partner meetings or as and when there is a new significant event and learning is cascaded to all relevant staff.
Infection prevention audit and actions
The Annual Infection Prevention Control audit is completed by Elisa Owen. Supported by Kim Schesselman
As a result of the audit, the following things have been changed at St Mary’s Surgery:
Thermometer bag to transport vaccinations has been purchased and now being used appropriately.
Urine specimen collection is constantly under review and any changes cascaded to staff and patients as appropriate.
An audit on minor surgery is undertaken by Dr Katherine Mercer annually. No infections were reported for patients who had had minor surgery at the Surgery.
Clinical rooms are to remain free from clutter to facilitate dusting/cleaning procedures and prevent any cross contamination.
The St Mary’s Surgery undertake the following audits.
- Annual Infection Prevention and Control Audit.
- Minor surgery outcomes audit annually.
- Cleaning audit (tick sheets completed by the contractor weekly – full audit completed monthly) monitored by St Mary’s Surgery. Outcomes reviewed, using the guidelines within the National Standards of Healthcare Cleanliness 2025, released by NHS England.
- Each consulting room has an auditable cleaning log ensuring the appropriate cleaning of equipment between patients is carried out by the clinician in each room. This is logged.
- Hand Hygiene audit annually.
Risk assessments
Risk assessments are carried out so that best practice can be established and then followed.
Legionella (Water) Risk Assessment: The practice has conducted/reviewed its water safety risk assessment to ensure that the water supply does not pose a risk to patients, visitors or staff.
Immunisation: As a practice we ensure that all of our staff are up to date with their Hepatitis B immunisations and offered any occupational health vaccinations applicable to their role (i.e. MMR, Seasonal Flu). We take part in the National Immunisation campaigns for patients and offer vaccinations in house and via home visits to our patient population.
Other examples:
We now aim to be a clutter free surgery to prevent cross contamination and facilitate dusting /cleaning procedures.
Posters within the surgery are all laminated, hoovered and disinfected weekly.
Curtains: The NHS Cleaning Specifications state the curtains should be cleaned or if using disposable curtains, replaced every 6 months. To this effect our curtains are steam cleaned every 6 months which is certified. The modesty curtains although handled by clinicians are never handled by patients and clinicians have been reminded to always remove gloves and clean hands after an examination and before touching the curtains. All curtains are regularly reviewed and changed if visibly soiled. The window blinds are very low risk and therefore do not require a particular cleaning regime other than regular vacuuming to prevent build-up of dust.
Toys: We have no toys in the practice.
Hand washing sinks: The practice has clinical hand washing sinks in every room for staff to use. Instructions for effective handwashing is next to each sink. Some of our sinks do not meet the latest standards for sinks but we have removed plugs, covered overflows and reminded staff to turn of taps that are not ‘hands free’ with paper towels to keep patients safe. We have also replaced our liquid soap with wall mounted soap dispensers to ensure cleanliness.
Training
All our staff receive training in infection prevention and control.
Clinical and non-clinical receive training in Infection Prevention Control via Practice Index
Policies
All Infection Prevention Control related policies are in date for this year.
Policies relating to infection prevention and control are available to all staff and are reviewed and updated annually and all are amended on an on going basis as current advice, guidance and legislation changes.
Infection Control policies are circulated amongst staff for reading. Discussed at clinical meetings when there has been any significant changes.
Responsibility
It is the responsibility of each member of staff, to be familiar with this statement and their roles and responsibilities under this.
Review date
April 2026
Responsibility for Review
Reasonability for reviewing and producing the Infection Prevention Control Annual Statement.
Lead Nurse – Elisa Owen Supported by Kim Schesselman
For and on behalf of St Mary’s Surgery