Infection Control Annual Statement

Infection Control Annual Statement - 2026

Purpose of the Annual Statement

The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance the Infection Prevention and Control (IPC) Lead to produce an annual statement.  This statement should be made available to anyone who wishes to see it, including patients and regulatory authorities and should also be published on the Practice website.  It summarises:

• Any infection transmission incidents and any action taken (these will have been reported in accordance with our learning events procedure)
• Details of any infection control audits undertaken, and action taken
• Details of any risk assessments undertaken for prevention and control of infection
• Details of any staff education and training
• Any review and update of policies, procedures and guidelines

Infection Prevent and Control (IPC) Leads:

GP Lead:                      Yasser Chaudhry
Nurse Lead:                 Emily Hynes
Premises Lead:            Claire Clark    

Learning events relating to infection transmission incidents

Learning 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 learning events are reviewed in the practice quality and review meetings and learning is cascaded to all relevant staff.  

In the past 12 months there have been zero infection transmission incidents (learning events).

Audits

Routine audits are carried out on a regular basis and are ongoing.

• Hand Hygiene Audit:  All new staff have an IPC induction, complete an IPC training module, and undertake the hand washing audit.  Existing members of staff complete the hand washing audit annually, alongside the yearly online training for Infection Control.

• National Cleanliness Standards Audits:  We are continuing to work hard to be  compliant with the National Standards of Healthcare Cleanliness.   To make sure every area of the practice stays clean and safe, we carry out regular cleaning checks. These checks are done according to how each area of the building is used and the level of risk involved. This helps us make sure our cleaning routines are always suitable, effective, and meet national expectations.

• Clinical room curtains:  The frequency for changing clinical room curtains is based on the room’s functional risk (FR1-FR6) category.  We are currently reviewing and risk-assessing all clinical areas so that curtain changes follow the correct schedule for each category.  Curtains that are visibly soiled are replaced immediately.  We use disposable curtains at the Practice, and systems are in place to ensure they are changed according to the Schedule or sooner if needed.  Rooms requiring curtain changes are identified on our intranet, with additional assurance provided through spot checks.

The cold chain audit is carried out annually.  A vaccine audit is carried out monthly.

• Sharps (needles) and waste management audits are carried out regularly throughout the year.

• In March 2026 IPC audits and visits were conducted across both sites. These audits highlighted certain areas that require improvement for the practice to comply with best practice guidance relating to IPC.

Actions Completed

• Following findings from the cleaning and IPC audits, which highlighted gaps in routine cleaning, further discussions have taken place with the cleaning team. Work is underway to develop a new, detailed cleaning specification outlining responsibilities for the cleaners, including frequency of decontamination and approved products.    For the clinicians, we have recently introduced a computerised cleaning log to record the cleaning of equipment between each patient, as well as at the start and end of clinical sessions.  This provides an auditable record of compliance and enables us to monitor standards and give timely feedback to clinicians where needed.

• All clinicians have been reminded to remove unnecessary items and excess or unused equipment from their rooms. This is supported by regular spot checks and reminder communications to maintain a minimal‑clutter, easy‑clean environment.  Further storage and clutter audits are planned, with the aim to extending this to non-clinical areas, to ensure good organisation across the Practice and prevent build-up of unnecessary equipment. 

• Fabric chairs have been phased out at Glinton. At Market Deeping, the plan remains to replace all chairs with plastic or washable alternatives, prioritising heavily stained chairs as funding allows.

• As part of the long‑term improvement plan, IPC advice will be sought before any works involving clinical room handwashing facilities. Domestic sinks currently in use in some clinical rooms are being reviewed so they can be replaced with sinks that meet clinical and IPC standards in the future, as funds allow. 

• The building is extremely hot in some treatment rooms during the summer months. Identifying suitable cooling units that remain fully IPC compliant has proven challenging; however, this is actively being reviewed to find an appropriate solution.

• The Dossett room is the only clinical use area still carpeted, and we are currently reviewing and costing its replacement with appropriate floor covering.

• Waste segregation processes have been reviewed, with checks undertaken to ensure all clinical waste streams are correctly colour‑coded and that foot‑operated clinical waste bins are available and correctly positioned.

• Staff IPC training compliance was reviewed to ensure all staff (both clinical and non-clinical) remain up-to-date with mandatory IPC education, with training provision expected to change in the coming year. 

• IPC‑related policies and procedures have been reviewed and updated where required, with changes communicated to relevant staff.

Risk assessments

We undertake a range of infection prevention and control risk assessments across the Practice to ensure a safe and compliant clinical environment. These include:

• Staff immunisation requirements, ensuring all staff receive vaccinations appropriate to their role.

• Water safety, including routine monitoring and control measures for Legionella.

• Sharps (needles) safety, reviewing the safe use, placement and disposal of sharps), and identifying any emerging risks.

• Waste management, ensuring correct segregation, storage and disposal of clinical and domestic waste streams.

• PPE availability and suitability, confirming that appropriate protective equipment is consistently accessible to all staff.

• Hand hygiene facilities, assessing the adequacy and accessibility of sinks, soap dispensers and alcohol gel stations in all relevant areas.

• Decontamination processes for reusable equipment, ensuring cleaning methods remain safe, effective and in line with current guidance.

• Environmental and premises‑related risks, including the suitability of flooring and surfaces.

• Vulnerable patient groups, including work underway to improve vaccination access and uptake for housebound patients.

Staff Education and Training

All staff are required to complete mandatory IPC training each year.

IPC issues or updates are to be discussed regularly throughout the year and are discussed in staff meetings. IPC is now a standard item on the agenda for our quarterly TARGET/Training meetings.

Staff are encouraged to raise any IPC concerns with the Practice Manager or IPC lead.

Any review of Policies, Procedures and Guidelines

The IPC policy is reviewed regularly to ensure it remains in line with current, evidence‑based guidance.  Theatre‑related policies and procedures are also reviewed routinely to ensure compliance with the latest advice, guidance and legislation, and all documents are accessible to staff via Teamnet. New staff members are directed to familiarise themselves with the location and content of these policies as part of their induction.

Cleaning specifications, frequencies and overall standards of cleanliness are reviewed on an ongoing basis, and we work closely with the cleaning team to ensure the surgery is maintained to a high standard.

IPC advice to Patients

We encourage all patients to attend for their routine immunisations, and eligible individuals receive regular reminders to book appointments. This includes baby and childhood vaccinations in line with the updated national schedule, as well as RSV, pneumonia, and shingles immunisations. Parents and guardians are sent timely invitations and reminders for children’s vaccines and are encouraged to speak with practice staff if they need further information or support in making informed decisions about immunisation.

Responsibility

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

The Infection Prevention and Control Lead and the Practice Manager are responsible for reviewing and producing the Annual Statement.  The next review date for this Statement is March 2027.