Infection Control Annual Statement


This annual statement will be generated each year in January 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. It summarises:

  • 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 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 Wickham Surgery Lead for Infection Prevention and Control: Rachel Doherty, Lead Nurse.

The IPC Lead is supported by: Claire Douglass

Rachel Doherty attends quarterly infection control forums (when covid pandemic allows) and keeps updated on infection prevention practice. Rachel also maintains a relationship with the CCG infection prevention team accessing their advice and support as needed.


Infection transmission incidents (Significant Events)

Significant 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 significant events are reviewed in the monthly departmental team meetings, quarterly significant event staff  meetings and learning is cascaded to all relevant staff via a monthly newsletter

In the past year there have been 0 significant events related to infection control. Learning from these events included:

  • There may be an under reporting of clinical incidence as patient contacts are back at normal levels. We continue with normal level of service, but there may be a lack of recognition and reporting for this area. We recognise the need to maintain reporting of events and subsequent learning for positive future outcomes.
  • We need to maintain a no blame culture for significant events and recognise the need for learning around events and near misses

Waste Audit

This was completed for both Droxford and Wickham sites in January 2024 and the results were fed back to the partners

  • Segregation of waste needs to be adhered to
  • Hand towels to fit each size dispenser need to be sourced
  • All sharps boxes need dating, signing and use of temporary closure when not full.
  • Training is provided for waste management at Induction and annually – but this isn’t reflected in the waste audit accurately. This needs to be completed by all clinical staff annually and non-clinical staff bi-annually.

Infection Prevention Audit and Actions

The Annual Infection Prevention and Control audit was completed by Rachel Doherty on 2.5.2024. 

As a result of the audit, the following things have been changed in Wickham Surgery

  • Droxford cleaning has since changed to a different provider and is much improved.
  • Since changing cleaning providers at Wickham, the cleaning standards have vastly improved.
  • Nothing to be stored above cupboards in clinical rooms.
  • Shelving to be minimised in consulting rooms
  • Paperwork, equipment and books to be kept to a minimum on shelves in GP rooms
  • Clinician chairs have almost all been replaced now to impermeable material.
  • Privacy curtains in some areas were reduced to annual changes but need to remain at 6 months for appropriate areas – nurses clinic rooms and GP rooms
  • Waste bins in toilet areas to be replaced or removed
  • Plug socket covers have been placed on to fridge plugs 
  • Nurse wing – dirty and clean utility rooms to go back to being locked with keypads being fitted
  • Fridges have been serviced at annual calibration time
  • Fridge temperatures need to be checked at least once daily.

Minor surgery is no longer taking place within the surgery. This will be reviewed annually and an audit put in place if these recommence.

The Wickham Surgery plan to undertake the following audits in 2024:

  • Annual Infection Prevention and Control audi
  • Minor Surgery outcomes audit if these restart
  • Domestic Cleaning audit
  • Clinical Waste audit
  • Cold chain audit

Infection Prevention training

All staff are expected to complete infection prevention and control training (either clinical or non-clinical as per their role) via Blue Stream. This was audited on 2.5.2024 and were as follows

  • 61 staff members with active accounts
  • 30 had not completed Infection Prevention training in the last year including 12 clinical members of staff. 
  • 2 had not ever done the unit on this platform – but were either new staff or had done training on another platform in the last year/maternity leave/long term sick leave.

Action points from this audit

  • Practice manager informed of findings and she wishes to cascade and manage this.
  • Add this unit to all non-clinical staff roles for induction (already in place for clinical)
  • Those returning from sick/maternity – to be given time to complete on return and their manager will be responsible for this

Risk Assessments 

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

Legionella (Water) Risk Assessment: The practice outsources this to Sweetbriar who conduct and review water safety risk assessment to ensure that the water supply does not pose a risk to patients, visitors or staff.

Immunisation: As a practice we ensure that all of our staff are up to date with their Hepatitis B immunisations and offered any occupational health vaccinations applicable to their role (i.e. MMR, Seasonal Flu, covid vaccination). We take part in the National Immunisation campaigns for patients and offer vaccinations in house and via home visits to our patient population and have taken part in the covid-19 vaccination programme both within our surgery and as home visits as appropriate.

Curtains: The NHS Cleaning Specifications state the curtains should be cleaned or if using disposable curtains, replaced every 6 months. To this effect we use disposable curtains and ensure they are changed every 6-12 months. The window blinds are very low risk and therefore do not require a particular cleaning regime other than regular vacuuming to prevent build-up of dust. The modesty curtains although handled by clinicians are never handled by patients and clinicians have been reminded to always remove gloves and clean hands after an examination and before touching the curtains. All curtains are regularly reviewed and changed if visibly soiled. Disposable curtains were removed from clinical rooms when used as a “hot room” for covid purposes.

Toys:  NHS Cleaning Specifications recommend that all toys are cleaned regularly and we therefore provide only wipeable toys in waiting / consultation rooms. All toys remain removed since covid-19 pandemic.

Cleaning specifications, frequencies and cleanliness: We have a cleaning specification and frequency policy which our cleaners and staff work to. An assessment of cleanliness is conducted by the cleaning team and logged. This includes all aspects in the surgery including cleanliness of equipment.

Hand washing sinks: The practice has clinical hand washing sinks in every room for staff to use. 



All our staff receive annual training in infection prevention and control. This is done via Blue Stream training academy (elearning) and lunch and learn in house training.

Rachel Doherty attends quarterly IPC meetings led by ICB and maintains communication with them as needed for more specific information



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

Policies relating to Infection Prevention and Control are available to all staff and are reviewed and updated annually, and all are amended on an on-going basis as current advice, guidance and legislation changes. Infection Control policies are circulated amongst staff for reading and discussed at meetings on an annual basis. 



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


Review date

2nd May 2025


Responsibility for Review

The Infection Prevention and Control Lead and the Practice Managers are responsible for reviewing and producing the Annual Statement.

Rachel Doherty - Urgent Care Nurse Lead

For and on behalf of the Wickham Surgery