Practice Policies

Infection Control Annual Statement 2025

Purpose

 

This annual statement will be generated each year 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. This report will be published on the practice website and will include the following summary: 

 

  • Infection transmission incidents and actions taken. 

  • IPC audits undertaken and subsequent actions implemented. 

  • Risk assessments undertaken and any actions taken for prevention and control of infection. 

  • Staff training 

  • Review and update of IPC policies, procedures, and guidelines  

  • Antimicrobial prescribing and stewardship. 

 

This statement has been drawn up by Beverley Patrick-Booth (IPC nurse leads at College Lane Surgery) 

 

Infection transmission incidents (significant events)

 

Significant events (which may indicate good practice as well as challenging events) are discussed at meetings to allow staff to be appraised of areas of best practice but also as a learning event for changes which that might lead to further improvement. Negative events are reported via a significant events form and are reviewed by management. These are reviewed in a quarterly meeting. Any learning points are cascaded to all relevant staff where an action plan, including audits or policy review may follow.  

In the past year there has been 0 significant raised that relate to infection control. There have been 0 complaints made regarding cleanliness or infection control.  

 

IPC audits undertaken and actions.

 

The annual IPC audit was completed 20/05/2024 externally by the Infection Control team. There is also an upcoming planned inspection scheduled for Tuesday 17th June 2025. Our last inspection generated a score of 94%. The actions discussed/ identified with the IPC inspector and IPC lead nurse have been actioned by the practice in a timely manner set out by the audit results.  

 

A full IPC audit is now completed annually and externally by the Infection Control Team. In addition, to the IPC audit the following audits are performed regularly: 

  • Handwashing audits (applicable to all staff including new starters, locums, and students) 

  • Store cupboard audits 

  • Domestic cleaning audits (completed by external company as well as team) 

  • Clinical room spot checks 

  • Sharps audits 

 

Risk Assessments: 

 

Regular risk assessments are carried out so best practice can be established; risk is minimised to be as low as reasonably practicable.  

In the last year, the following risk assessments were carried out/ reviewed: 

  • Legionella (water) risk assessment: This is performed every month. Our last external audit was completed 21/05/2024. 

  • Control of substances hazardous to health (COSHH) 

  • Disposal of waste 

  • Sharps injury 

  • Risk of body fluid spills 

  • Use of personal protective equipment 

  • Cleaning standards/ specifications: We work with our cleaners to ensure the surgery is kept as clean as possible. 

  • Immunisations: As a practice we ensure all out staff are up to date with Hepatitis B and most recently the MMR immunisations, staff are also offered their annual influenza vaccinations as an occupational risk. We take part in the National Immunisations Campaigns for patients and offer in house appointments as well as home visits.  

 

Staff training: 

 

In addition to staff being involved in risk assessments and significant events at College Lane Surgery, all staff receive IPC induction training upon commencing employment. Thereafter, all staff complete their mandatory training via eLearning modules on ELFH.  

 

Review and update of IPC policies, procedures, and guidelines: 

 

All Infection Prevention and Control related policies have been reviewed and updated in the past year. These are available to all staff and are reviewed at least annually and are amended on an ongoing basis as per current guidance, advice, and legislation changes. Infection Control policies are circulated amongst staff for reading and discussed at meeting on an annual basis. They are available in all clinical rooms and within the building and can be accessed on Teamnet. 

 

Antimicrobial prescribing and stewardship: 

 

At College Lane surgery we are working with the Lowering Antimicrobial prescribing (LAMP) project. Dr Myerscough (clinical lead) attends quarterly meetings and LAMP reports are reviewed frequently to reduce inappropriate use of antimicrobial drugs. We are committed to working together with patients to ensure that antibiotics are prescribed where clinically appropriate.  

 

Please click on the link below for the most up to date LAMP report:

 

College Lane Surgery Lamp Report

 

Responsibility: 

It is the responsibility of each individual/ staff member to be familiar with this statement and their roles and responsibilities under it. 

 

Review date and responsibility: 

The Infection Prevention and Control lead is responsible for reviewing and producing this annual statement. This annual statement will be updated on or before 05/2025

Page last reviewed: 12 June 2025
Page created: 20 January 2021