Purpose
This annual statement will be generated each year in July, 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 organisation’s 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 carried out 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 PICKERING MEDICAL PRACTICE is ALISON HART BETTANY (ANP)
The IPC Lead is supported by SIOBHAN GORMAN (PM).
a. 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 in 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 which 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 3 significant events raised which related to infection control. There have also been 0 complaints made regarding cleanliness or infection control.
b. Infection prevention audit and actions
- A full IPC Audit was conducted in September 2024 by the previous IPC Lead (Ria Flinton) and the newly appointed IPC Lead (Alison Hart-Bettany). This will be repeated on an annual basis. An Action Plan was produced based on the findings and IPC recommendations made by RF & AHB and presented to the Practice Management and Partners. This Action Plan is a working document and improvements are being made.
- One of the priority areas is to improve the general cleaning standards and this is ongoing. AHB is working with and having monthly meetings with our cleaning company manager to implement these improvements.
- Although the National Standards of Healthcare Cleanliness 2025 does not apply to General Practice currently we are striving to implement this into practice as we feel it is good practice to do so. This will require regular cleaning audits of all areas supported by our cleaning company.
- We are in the process of developing a 5-year estates improvement plan to ensure all areas are and are maintained to a high IPC standard.
- We anticipate that we are due a CQC inspection soon and are working towards maintaining our current ‘Good’ rating and striving to achieve an ‘Outstanding’ rating.
c. Risk assessments
Risk assessments are carried out so that any risk is minimised and made to be as low as is 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:
- Sanitary waste
- Fabric noticeboards
- Carpeted flooring
- Sluice sink
In the next year, the following risk assessment will also be reviewed:
- Toys & pictures/photos in clinical rooms.
d. Training
In addition to staff being involved in risk assessments and significant events, at Pickering Medical Practice all staff and contractors receive IPC induction training on commencing their post. Thereafter, all staff receive refresher training annually via online training (Practice Index) and ad hoc IPC training events organised by our IPC Lead. The last event took place on the 21st of January 2025 and the following IPC areas were covered:
- Hand Hygiene and Hand Hygiene Audit.
- Safe management of blood and body fluids
e. Policies and procedures
A review and update of all the infection prevention and control-related policies, protocols and supportive local and national guidance are being updated. These are being added to one Practice Handbook and once completed will be available for all staff on Practice Index. The Handbook will be reviewed and updated annually. Additionally, all policies are amended on an ongoing basis as per current advice, guidance and legislation changes.
Policies include, but are not limited to:
- Antimicrobial stewardship
- Aseptic technique
- BBVs (blood-borne viruses)
- Carpets and soft furnishings protocol
- difficile (Clostridioides difficile)
- CJD (Creutzfeldt-Jakob disease)
- Hand hygiene and handwashing audit
- Infection control inspection checklist
- Invasive devices
- MRGNB, including CPE
- MRSA
- Notifiable diseases
- Outbreaks of communicable disease
- Patient placement and assessment for infection risk
- PPE (personal protective equipment)
- Privacy Curtains Protocol
- PVL-SA (Panton-Valentine Leukocidin staphylococcus aureus)
- Respiratory and cough hygiene
- Respiratory illness
- Safe disposal of waste
- Safe management of blood and body fluids
- Safe management of care equipment
- Safe management of linen (including uniforms and workwear)
- Safe management of sharps and inoculation injuries
- Safe management of the care environment
- Scabies
- SICPs and TBPs (standard infection control precautions and transmission-based precautions)
- Specimen collection
- Staff exclusion from work
- Venepuncture
- Viral gastroenteritis/Norovirus
- Pest control
f. Responsibility
It is the responsibility of all staff members at Pickering Medical Practice to be familiar with this statement and their roles and responsibilities under it.
g. Review
The IPC Lead (Alison Hart-Bettany) and the Practice Manager (Siobhan Gorman) are responsible for reviewing and producing the annual statement. This annual statement will be updated on or before the 29/07/26
Signed by
Alison Hart -Bettany
For and on behalf of PICKERING MEDICAL PRACTICE
AHB 29/07/25