Infection Control Annual Statement
(November 2024 – October 2025)
1. PURPOSE
In line with the Health and Social Care Act 2008: Code of practice on prevention and control of infection (July 2015) and its related guidance, this Annual Statement will be generated each year. It will summarise:
- Any infection transmission incidents and any lessons learnt and action taken
- Details of any infection prevention and control (IPC) audits undertaken and any subsequent actions taken arising from these audits
- Details of any issues that may challenge infection prevention and control including risk assessment undertaken and subsequent actions implemented as a result
- Details of staff IPC training
- Details of review and update of IPC policies, procedures and guidance
- To highlight priorities for the upcoming year.
2. INFECTION CONTROL LEAD
The Infection Control Lead will enable the integration of Infection Control principles into standards of care within the practice, by acting as a link between the surgery and Leicester, Leicestershire and Rutland Infection Control Team. They will be the first point of contact for practice staff in respect of Infection Control issues. They will help create and maintain an environment which will ensure the safety of the patient / client, carers, visitors and health care workers in relation to Healthcare Associated Infection (HCAI).
The Infection Control Lead will carry out the following within the practice:
- Increase awareness of Infection Control issues amongst staff and clients
- Help motivate colleagues to improve practice
- Improve local implementation of Infection Control policies
- Ensure that practice based Infection Control audits are undertaken
- Assist in the education of colleagues
- Help identify any Infection Control problems within the practice and work to resolve these, where necessary in conjunction with the local Infection Control Team
- Act as a role model within the practice
- Disseminate key Infection Control messages to their colleagues within the practice
Practice Infection Control Lead: Asiya Maula/Dominic Greenyer
Cleaning and Decontamination Lead: Fatema Contractor
3. SIGNIFICANT EVENTS
There have been no significant events reported regarding infection control issues in the period covered by this report.
4. AUDITS / RISK ASSESSMENT
The following audits/ assessments were carried out in the practice
- Infection control annual audit completed- 25/09/2023
- Handwashing Audit – ongoing
- PPE audit – ongoing
- LLR PCL Site review 29/09/23 – 100% compliance
- Infection Control Risk assessment – ongoing (fan use risk assessment Sept 2023)
- Vaccine storage audit October 2024
- Environmental cleaning audit – completed by Servicemaster
- Prescribing Audit completed July 2024
Audit Key findings
Infection control audit
- Site cleaning and waste policies in place and procedures being followed
- Appropriate Contracts in place to ensure clinical waste, confidential waste and regular waste are disposed of appropriately
- Site is appropriate for use and configured to allow easy cleaning in clinical areas
- Good provision of hand washing facilities throughout the clinic
- Minor remedial wall and ceiling cracks noted.
- Review of staff immunisations – ongoing
Prescribing Audits
- Appropriate prescribing seen for antibiotics following local LMSG guidelines
Hand hygiene audit
- Good compliance and awareness of hand hygiene policy
- Printed guides available at sinks, need to source additional signage for those sinks without
Control of Legionella
- Hot and Cold water checks and maintenance completed weekly
- Risk of legionella contained
- All initial checks and system sterilisation in place
- Water samples sent and reported clear (August 2023)
- Risk assessment update required
5. STAFF TRAINING
Staff complete annual infection control training through the Bluestream training portal, this is renewed annually and audited through the bluestream module. Currently 80% of the expected 100% of staff have completed this training within the last 12 months, with 100% have completed some form of infection control training in the last 24 months.
Due to recruitment and new staff NOT all staff have attended Infection Control refresher training in the last 1 year. Both infection Control Leads for the Practice have attended Infection Control training in the last year.
Our nurses are performing regular cleaning of communal areas and our clinicians routinely clean their space, equipment and hands in-between appointments.
6. POLICIES, PROTOCOLS AND GUIDELINES
The Policies below have been updated this Year. They are reviewed annually or earlier when appropriate due to changes in regulations and evidence based guidance.
- Antimicrobial stewardship
- Aseptic technique
- BBVs (Blood-borne viruses)
- C. difficile (Clostridioides difficile)
- CJD (Creutzfeldt-Jakob disease)
- Hand hygiene
- Invasive devices
- MRGNB, including CPE (Multi-resistant Gram-negative bacteria, including carbapenemase-producing Enterobacterales)
- MRSA (Meticillin resistant Staphylococcus aureus)
- Notifiable diseases 3.00 November 2023
- Outbreaks of communicable disease
- Patient placement and assessment for infection risk
- PPE (Personal protective equipment)
- PVL-SA (Panton-Valentine Leukocidin staphylococcus aureus)
- Respiratory and cough hygiene
- Respiratory illnesses
- Safe disposal of waste, including sharps
- Safe management of blood and body fluid spillages
- Safe management of care equipment
- Safe management of linen, including uniforms and workwear
- Safe management of sharps and inoculation injuries
- Safe management of the care environment
- Scabies
- SICPs and TBPs (Standard infection control precautions and Transmission based precautions)
- Specimen collection
- Venepuncture
- Viral gastroenteritis/Norovirus
All cleaning schedules have been reviewed and reshared with cleaning contractor
7. PRIORITIES AND KEY POINTS FOR THE NEXT 12 MONTHS
Site Improvements
- See audit recommendations
- To continue to work with the cleaning company to maintain expected standards of cleanliness.
- Ongoing work to assess new staff immunisation status.
- Revision of roles and responsibilities of infection control lead to reflect any changes
- New theatre and recovery spaces – implement cleaning protocols for FR2 space
- Continue rolling programme of audit, risk assessment and policy update
Training
- To ensure all staff within the next 3 month complete any training to ensure that infection control training is completed every 12 months to ensure all are kept up to date
- Implement IPC update Newsletter
- Publish annual statement on website
- Ensure Infection Control Lead attends regular virtual meetings for IPC and this is documented within The Health Suite IPC policy