Infection Prevention and Control

Annual Statement

Purpose

This annual statement will be generated each year in November 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 The Tollgate Practice is Julie Swain, Nurse Practitioner.

The IPC lead is supported by Michelle Black, Nurse Practitioner.

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 0 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

The CQC inspection report dated 19th May 2021 indicated there were no documented handwashing audits or monitoring.  A regular handwashing audit is recorded by the IPC lead and is recorded on a template document stored on the Shared Drive.  The result of the most recent Audit can be found scanned onto the Shared Drive.

An external IPC audit took place on 30th September 2021 by Infection Control Training Ltd.  Actions from this audit included:

  • Changing of all bins within clinical rooms to a ‘flip-top’ type
  • Repair of any damage to walls
  • Painting of walls throughout the Practice in admin and clinical rooms
  • Changing the use of K-Y Jelly to single-use sachets
  • Weekly clean of all clinical rooms with Clinell wipes and document

Internal audits that have been conducted within the previous year include hand washing audits for clinical staff and Blue Stream Academy eLearning for all staff on Infection Control and Hand Hygiene.

Blue Stream eLearning will be undertaken annually.  The hand washing audit will take place at regular intervals, at least annually.  An IPC review by an external organisation will take place annually.

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 carried out/reviewed:

The following assessments have been conducted during the period covering this annual statement:

  • Single Use Instruments risk assessment
  • COVID-19 risk assessment
  • Staff vaccination and immunisation record updates
  • Ongoing training through eLearning

In the next year, the following risk assessment will also be reviewed:

  • Staffing, new joiners and ongoing training
  • COSHH
  • Cleaning standards
  • Curtain cleaning and changes

Training

In addition to staff being involved in risk assessments and significant events, at The Tollgate Practice all staff and contractors receive IPC induction training on commencing their post. Thereafter, all staff receive refresher training annually.

Various elements of IPC training in the previous year have been delivered at the following times:

  • Staff meetings
  • External assessments
  • eLearning

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:

  • COSHH Risk Assessment Guidance
  • Safe Water Policy (Legionella)
  • Cleaning Standards and Schedule Policy
  • Infection Prevention Control Policy
  • Safe Use and Handling of Chemicals Policy
  • Staff Immunisation Policy

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 The Tollgate Practice to be familiar with this statement and their roles and responsibilities under it.

Review

The IPC lead and Practice Manager are responsible for reviewing and producing the annual statement.

This annual statement will be updated on or before 1st November 2022.

Signed by Annette Bloomfield.

For and on behalf of The Tollgate Practice.