Infection Control Annual Statement

Purpose of this statement  

This annual statement will be generated each year in April 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 taken/planned.   
• Details of any risk assessments undertaken for prevention and control of infection.
• Antimicrobial Stewardship .
• Details of staff training.
• Any review and update of policies, procedures, and guidelines   

Infection transmission incidents (Significant Events)  

Significant events (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 monthly at the Clinical meeting and learning is cascaded to all relevant staff.  

In the past year there have been no significant events reported related to infection prevention and control.   

The Lead Practice Nurse attends the monthly Clinical Meeting and discusses Infection Prevention & Control matters.  

Infection Prevention Audit and Actions  

The Infection Prevention and Control audit for 2025 has been completed by Leanne Daniels (Nurse Associate Trainee) as a delegated responsibility from the IPC Lead Practice Nurse, with support from a PCN Project Manager. Key improvements since last year’s audit:  

• The cleanliness of curtain rails has greatly improved.  
• The cleanliness of couch frames has markedly improved with only a small number of exceptions.  
• All rooms bar one have the requisite hand washing poster.  
• Much better knowledge about inoculation injuries with better information about what to do available in clinical areas.  
• Very few disposable curtains out-of-date.  
• Number of non-wipeable chairs reduced considerably.  
• Implementation of regular and consistent monthly cleanliness audits.  
• General standard of cleanliness.  

The following actions are planned for this year:   

• Update the planned maintenance programme.  
• Update the planned replacement programme. 
• Address a small number of urgent building issues, for instance radiators with significant surface damage.  
• Review and implement a process for equipment decontamination and labelling.  
• Reiterate and apply policy on storage of couch rolls.  
• Review storage facilities and the cleaning thereof.  
• Reiterate and apply best practice for Sharps Management, specifically the proper use of Sharps bins.  
• Review and implement revised proves for recording receipt of vaccines. 

Dean Cross Surgery plan to undertake the following audits in 2025.  

• On-going hand hygiene practice audits  
• Monthly cleaning audits.  
• Safe management of care equipment audit. 

Risk Assessments   

Risk assessments are carried out to manage and control potential risk. In the last year the following risk assessments were carried out / reviewed:  

Legionella: Following an initial in-house risk assessment, an external expert was commissioned to undertake a full review of the management of Legionella risks across the Practice; this will be followed up with ongoing monthly risk reduction measures.  

Desk/sink surfaces: Wooden fixed desks and sink surrounds remain an outstanding issue; mitigation is being applied to the desks (in the form of laminate) as an interim measure, the sink surrounds will require a permanent solution. Funding is being sought to address this.  

General room maintenance walls/radiators/floors: Carpet has been replaced with hard flooring in reception and some thoroughfare areas. Walls and radiators remain an outstanding risk, mitigated by the cleaning programme, but will require a short/medium/long term maintenance programme.  

Training  

Clinical staff and non-clinical staff undertake infection control training via Practice Index; this is completed during induction and then as part of annual update training. Practice Index has in-built monitoring that alerts staff and managers when updates are required.  

Policies 

The Infection Prevention and Control policy (Group policy across Mewstone PCN) was updated in September of 2024.   

Policies relating to Infection Prevention and Control are available to all staff, reviewed and updated annually and amended on an on-going basis as current advice, guidance, and legislation changes.  

Antimicrobial Stewardship  

The Practice has repeated the audit of anti-microbial stewardship, and this is displayed on the staff information board. This will also be reported to a Practice Clinical Meeting.  

Review date  

March 2026 

The Infection Prevention and Control Lead and the Practice Manager are responsible for reviewing and producing the Annual Statement.