Infection Control Annual Statement

Infection Control Annual Statement



 This annual statement will be generated each year in February in accordance with the requirement 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 actions taken

·        Details of infection control audits undertaken and resulting actions taken

·        Details of any risk assessments undertaken for prevention and control of infection

·        Staff education and training

·        Any review and update of policies, procedures and guidance

·        Antimicrobial prescribing and stewardship

 Infection Prevention and Control (IPC) Lead

 IPC Nursing lead: Teresa Warwicker – Practice Nurse

IPC GP lead: Dr P Warwicker

Antimicrobial prescribing Lead:  Dr R Verma

Sepsis Lead: Dr R Verma

ICB Lead: Natalie Warman

IPC Support and queries:


Infection transmission incidents (Significant Events)

 Significant events (may involve examples of good practice as well as challenging events) are

investigated in detail to determine what can be learnt and indicate changes that might lead to future improvements.

All significant events are reviewed in monthly staff meetings and learning is cascaded to all relevant staff.

There were no significant events relating to Infection Control in the last 12 months.


Infection Prevention Audit and Actions

The Annual Infection Prevention and Control audits were completed by T Warwicker in August 2022 and February 2023.

As a result of these audits, the following actions were taken:

Patient Triage for infection risks continues, notices displayed in reception relating to infections e.g. Covid-19; Diarrhoea/sickness.

·        National Infection Prevention and Control MANUAL for England (NIPCM): January 2023 version put on IPC notice board. It reiterates the 10 Elements of Standard Infection control precautions (SICPS).

·        IPC Staff information 2023: this document is updated and put up in all areas of the practice to reflect the step-down in Covid-19 IPC procedures.

·        Disposable Curtains: these were updated in consulting rooms and the waiting room.

·        Clinical Waste: Updated information posters on the appropriate coloured bags to use for allocation of clinical waste in all rooms and stocked with the relevant bags.

·        Hand Hygiene Posters displayed in all areas of the practice to remind staff, this remains the most important factor in reducing the risk of transmission of infectious agents.

·        Upgrading of room 3 IPC equipment in next door building for potential use as patient consultation room.


An audit on Minor Surgery was carried out by Dr R Verma, less than 2% infections were reported, which is under the national guidance of 5%.  Next minor surgery audit will be carried out July 2023.

A hand Hygiene audit was undertaken in February 2023, this was discussed in a staff meeting and the relevant posters displayed.


The Grove Medical Centre practice plans to undertake the following audits in 2023

·        Annual Infection Prevention and Control

·        Minor Surgery

·        Hand Hygiene


Risk Assessments

Risk assessments are carried out so that best practice can be established. In the last year the following risk assessments were carried out/reviewed:

Privacy Curtains: In line with the National Standards of Healthcare Cleanliness 2021 and regulation 15 of the Health and Social Care Act 2008, curtains should be visibly clean with no blood or body substances, dust, dirt, stains or spillages. In light of this, disposable medical grade curtains are used in the consulting and waiting rooms. All curtains are regularly reviewed and were changed in February 2023.

Legionella (Water) Risk Assessment: In line with cleanliness assurance (Safe Management of the Care Environment), the practice conducts a monthly water safety risk assessment to ensure the water supply does not pose a risk to patients, visitors or staff.

Clinical Waste: As per the NHS Clinical Waste Strategy 2023, the appropriate segregation of waste is vital to reducing Net Zero carbon emissions within the NHS by 2040. Colour coded posters outlining the segregation of waste and suitable waste bag to use were put in the relevant rooms.

Safe Management of Blood and Bodily Fluids: In line with PHE (2019) Guidance on management of potential exposure to blood-borne viruses in emergency workers, it is essential that all health care workers pay careful attention to the appropriate policy, procedure when handling sharp instruments, syringes, blood and other body fluids (Exposure Prone Procedures EPPs).  Staff use the appropriate PPE relevant to the procedure; follow the decontamination guidelines re cleaning/spillages using the relevant biohazards kits where necessary. All staff use the standard infection control precautions (SICPs).

Cleaning specifications, frequencies and cleanliness: the practice provides and maintains cleaning schedules that facilitate the prevention and control of infections. These are checked daily.

An annual deep clean of the practice is due in July 2023.



 All staff receive annual training in infection prevention and control

·         All clinical and non-clinical staff have completed blue stream e-learning training

·         All staff receive updates at monthly meetings and via the IPC notice board

·         IPC is integrated into the induction process for all staff

·         IPC lead attends quarterly Practice Nurse IPC Forums organised by Surrey Heartlands ICB



All Infection Prevention and Control related policies are in date for this year.

These policies are available to all staff.

They are reviewed and amended on an ongoing basis in line with current advice, guidance and legislation changes.

All IPC policies are discussed with staff on an annual basis.



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


Antimicrobial Prescribing and Stewardship

Antimicrobials are a group of agents that either kill or inhibit the growth and division of micro-organisms. They include antibiotics, antiseptic, disinfectants, antiviral, antifungal, antibacterial and anti-parasitic medicines. Antimicrobial resistance (AMR) describes when micro-organisms evolve over time and no longer respond to any antimicrobial therapy.

The solution to reducing further AMR is Antimicrobial Stewardship (AMS), this is a healthcare wide system approach to promote and monitor judicious use of antimicrobials to preserve their future effectiveness.

·        The practice has systems in place to manage and monitor the use of antimicrobials e.g.  monitoring patients who may have severe infections such as sepsis to ensure they are treated promptly with suitable antimicrobials. Sepsis is reviewed at every monthly staff meeting and outcomes discussed.

·        The lead for sepsis and AMS attend monthly educational meetings where audits/prescribing events are analysed and best practice established.

·        The practice follows the NICE Summary of Antimicrobial prescribing guidance – managing common infections (updated February 2023).

·        The practice works in line with the Surrey Heartlands ICB Antimicrobial Optimisation Group which produces quarterly Microbial Matters Newsletters. This is distributed to all clinical staff.

·        Practice prescribers work closely with in-house pharmacists and lead PCN pharmacists to ensure standardisation of antimicrobial prescribing.

·        The practice promotes national antimicrobial awareness on its website as and when this arises.

·        The practice follows the Surrey Heartlands ICB Wound Management Formulary which promotes evidence based guidance on wound management and topical antimicrobials.

·        Best practice information is disseminated to all staff via monthly meetings.


 Review Date

 February 2024