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: Tracey Dugan, Practice nurse.

Rachel Doherty attends quarterly infection control forums and keeps updated on infection prevention practice.


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 weekly/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 6 significant events related to infection control. Learning from these events included:

  • Safe management of sharps and the sharps/splash injury procedures cascaded to broader team
  • Awareness of graphnet as a means of accessing xray results
  • Prompt review of chronic wounds on discharge from hospital

As a result of these events, Wickham Surgery has changed:

  • Leg washing assessment done on individual basis
  • Implemented the use of Heales Occupation health services and trialed use of Drayton Occupational Health Service

Infection Prevention Audit and Actions

The Annual Infection Prevention and Control audit was completed by Rachel Doherty in 28.1.2019.

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

  • Top shelves have been removed in doctors rooms
  • General store in nurses wing has been shelved and no stock at ground level
  • Cleaners rooms have brackets for mops to be hung over corresponding buckets, but not touching
  • Cleaners rooms have shelving and no stock on the floor
  • Cleaners logs signed off daily and kept
  • HCAs responsible for stocking and rotation of equipment in GP rooms and clean down of equipment weekly
  • Nothing to be stored above cupboards in clinical rooms
  • Quarterly checks to be done in clean and dirty utility rooms
  • Clinician chairs to be replaced with wipe clean chairs

An audit on hand washing was undertaken on 22nd July 2019. This was published in the staff newsletter the following month.

The Wickham Surgery plan to undertake the following audits in 2019:

  • Annual Infection Prevention and Control audit
  • Minor Surgery outcomes audit
  • Domestic Cleaning audit
  • Hand hygiene audit

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 has conducted/reviewed its water safety risk assessment to ensure that the water supply does not pose a risk to patients, visitors or staff. Legionella monitoring is brought in from Sweetbriar who run quarterly checks.

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). We take part in the National Immunisation campaigns for patients and offer vaccinations in house and via home visits to our patient population.

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 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.

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. Clinical staff are responsible for a daily clean down of equipment and work station and all equipment used in direct contact with patients’ is cleaned down between use.

Hand washing sinks: The practice has clinical hand washing sinks in every room for staff to use. Training All our staff recieve annual training in infection prevention and control. This is done via Blue Stream training academy (elearning) and a lunch and learn in house training. Hand hygiene training with the use of the light box has taken place in July 2019 – having borrowed the equipment from West Hants CCG infection control team – all staff proved to be washing hands well, everyone was reminded of correct handwashing procedure and areas that are frequently missed.



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 or with any significant change of circumstance 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. They can be found on the shared drive and also within docman.



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


Review date

1st January 2020


Responsibility for Review

The Infection Prevention and Control Lead and the Business manager - Ed Kennedy are responsible for reviewing and producing the Annual Statement.