Download the infection prevention and sontrol statement (PDF, 189KB)
Completing the Annual Statement for Infection Prevention and Control (Primary Care)
It is a requirement of The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance that the Infection Prevention and Control Lead produces an annual statement with regard to compliance with good practice on infection prevention and control and makes it available for anyone who wishes to see it, including patients and regulatory authorities.
As best practice, the Annual Statement should be published on the Practice website.
The Annual Statement should provide a short review of any:
- known infection transmission event and actions arising from this;
- audits undertaken and subsequent actions;
- risk assessments undertaken for prevention and control of infection;
- training received by staff; and
- review and update of policies, procedures and guidance.
Below is a suggested template for the Annual Statement compiled from national guidance and examples of best practice found on the internet. Practices can (and should) adapt the template and add further detail/headings/examples but the five key headings (above) must be included. If the practice are unable to complete one or more of the five key headings, it is likely that the practice are not compliant with the health and Social Care Act.
Infection Control Annual Statement
Purpose
This annual statement will be generated each year in February 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
The Emsworth Medical Practice has a lead for Infection Prevention and Control: Alexandra Kershaw
The IPC Lead is supported by:
Alexandra Kershaw has attended an IPC Lead training course regularly each year and keeps updated on infection prevention practice.
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 quarterly nurse and practice meetings and learning is cascaded to all relevant staff.
In the past year there have been no significant events raised that related to infection control.
Infection Prevention Audit and Actions
The Annual Infection Prevention and Control Audit was completed by Alexandra Kershaw in May 2023
As a result of the audit, the following things have been changed in Emsworth Medical Practice:
- Completed annual statement and uploaded to the website.
- Dust found on curtain rails, fed back to the cleaning company and they now do a monthly Audit of their cleaning practice.
- Face masks in store room out of date and swabs in Clinician trolleys out of date – disposed of.
- Curtains out of date in clinical rooms – creating folders in each of the treatment rooms to sign of to monitor IPC adherence
An Audit on Minor Surgery was undertaken by Alexandra Kershaw in Jan 2024.
No infections were reported for patients who had had minor surgery at the Emsworth Medical Practice.
As a result of the audit, the following things have been changed:
- Update Joint injection policy
- Disseminate the policy among the GPs undertaking the minor surgery
An Audit on hand washing was undertaken in [insert date]. This was discussed at the practice / staff / partner meeting.
The Emsworth Medical Practice plan to undertake the following audits in 2024:
- Annual Infection Prevention and Control audit
- Minor Surgery outcomes audit
- Domestic Cleaning audit
- Hand hygiene/asepsis audit
- Waste Management Audit
- Vaccine cold chain audit
- Sharps bin audit
Risk Assessments
Risk assessments are carried out so that best practice can be established and then followed. In the last year the following risk assessments were carried out / reviewed:
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:
Curtains: The NHS Cleaning Specifications state the curtains should be cleaned or if using disposable curtains, replaced every 6 months. To this effect we use disposable curtains and ensure they are changed every 6 months. 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. 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.
Toys: We have no toys in the practice.
Cleaning specifications, frequencies and cleanliness: We have a cleaning specification and frequency policy which our cleaners and staff work to. An assessment of cleanliness is conducted by the cleaning team and logged. This includes all aspects in the surgery including cleanliness of equipment.
Hand washing sinks: The practice has clinical hand washing sinks in every room for staff to use. Some of our sinks at our Westbourne site 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 annual training in infection prevention and control via the e-learning platform e-learning for health.
Policies
All Infection Prevention and 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 and discussed at meetings on an annual basis they are accessable on our shared H- drive.
Responsibility
It is the responsibility of each individual to be familiar with this Statement and their roles and responsibilities under this.
Review date: Feb 2025
Responsibility for Review
The Infection Prevention and Control Lead and the Kate Hope (Practice manager) are responsible for reviewing and producing the Annual Statement.
Alexandra Kershaw
IPC lead and ANP
For and on behalf of the Emsworth Medical Practice