Download the infection control policy (DOCX, 420KB)
IPC Annual Statement Report
Rough Hay Surgery 02/04/2024
Purpose
This annual statement will be generated each year in April 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. The report will be published on the practice website and will include the following summary:
- 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 the 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 lead for infection prevention and control at Rough Hay Surgery is Lisa Smith-Practice Nurse.
The IPC lead is supported by Leah Ward- Health Care Assistant.
Infection transmission incidents (significant events)
Significant events involve examples of good practice as well as challenging events.
Positive events are discussed at meetings to allow all staff to be appraised of areas of best practice.
Negative events are managed by the staff member who either identified or was advised of any potential shortcoming. This person will complete a Significant Event Analysis (SEA) form that commences an investigation process to establish what can be learnt and to indicate changes that might lead to future improvements.
All significant events are reviewed and discussed at several meetings each month. 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 have been 1 significant events raised that related to infection control. There have also been 0 complaints made regarding cleanliness or infection control.
Infection prevention Audit and actions
Quarterly audits are carried out throughout the year by the HCA, this year audits have been performed on 20/05/24, 12/08/24, 11/11/24, 03/02/25. Actions to follow as a result of these have been repair tile from wall in room 5 and replace open bins with pedal bins in clinical rooms for domestic waste.
Risk assessments
Risk assessments are carried out so that any risk is minimised to be as low as reasonably practicable. Additionally, a risk assessment that can identify best practice can be established and then followed.
In the last year, the following risk assessments were conducted/reviewed:
A suggested list, but one that is not exhaustive, could contain the following:
- Quaterly and annual ipc audits including general IPC and hand washing.
- Staff complete ongoing training and annual updates on bluestream, health assessments and DSE.
- COSHH sheets are kept filed and updated regarding new changes.
- SHL carry out all cleaning risk assessments.
- Privacy curtains are reviewed and changed six monthly or when stained if sooner by HCA.
- Staff vaccinations status are kept in individual files.
- Cleaning logs/ fridge temps are monitored daily.
- Sharp/wastage annual audits carried out via anenta.
- Water safety’s annually checked in legionella risk assessments.
In the next year, the following risk assessment will also be reviewed:
External IPC annual Audit will be carried out 12th march 2025 and actions will be carried out in a timely manner.
Training
In addition to staff being involved in risk assessments and significant events, at Rough Hay Surgery all staff and contractors receive IPC induction training on commencing their post. Thereafter, all staff receive refresher training annually.
HCA/NURSE are on the IPC educational webinar distribution list and carry out on ad hoc basis when they receive emails.
Policies and procedures
The infection prevention and control related policies and procedures that have been written, updated, or reviewed in the last year include, but are not limited, to: infection prevention control policy, uniform policy, clear desk policy, cold chain policy, ear irrigation policy, ecg policy, coshh policy and waste management.
Policies relating to infection prevention and control are available to all staff and are reviewed and updated annually. Additionally, all policies are amended on an ongoing basis as per current advice, guidance, and legislation changes.
Responsibility
It is the responsibility of all staff members at Rough Hay Surgery to be familiar with this statement and their roles and responsibilities under it.
Review
The IPC lead and HCA are responsible for reviewing and producing the annual statement.
This annual statement will be updated on or before 02/04/25