Purpose
This annual statement will be generated each year in September 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
St Paul’s Surgery Infection Prevention and Control Lead is Sister L Rogers (Practice Nurse).
The IPC Lead is supported by: The Practice Manager Philip Heiden and Health Care Assistant Lucy Clarke.
Sister Rogers will be attending an IPC Training course in October 2023 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 clinical incident meetings and learning is cascaded to all relevant staff.
the past year there have been no significant events raised that related to infection control.
Infection Prevention Audit and Actions
Since July 2022 there was a merge and we are now NHS Hampshire and Isle of Wight Integrated Care Board. As a result of this change instead of an annual audit there will be breakdowns of the audit which will be triannual. We continue to meet with Two Counties Cleaning every quarter for the cleaning audit.
The triannual Infection Prevention and Control audits were completed by Sister Rogers in March and June 2023. Sister Rogers took over from the previous IPC Lead, Sister A Sansome in January 2023.
- General management, Staff health, Staff training, Policies, Procedures and Guidelines, and Antimicrobial stewardship 16/6/23
- Clinical, Sharps, Waste and Domestic 30/3/23
- Environment, Hand hygiene & PPE, and Vaccines May 2022 – due to be completed in November 2023
As a result of the audit, the following things have been changed:
- Opti lube tubes have been changed to single use sachets.
- Clinell “I am Clean” tape has been ordered for labelling of equipment after each clean.
- Fan has been removed from the wall outside TR3 and wall made good.
- Annual cold chain training has been made mandatory to all staff.
- Process for E. Coli data collecting has been introduced and actioned.
- The IPC Policy has been updated.
- Couch in TR3 has been replaced.
- Our HCAs carry out monthly audits to check sharps bins and stock in all rooms are within date and comply with Standards of Operations (SOPs).
- Dressing Trolleys have been replaced.
As a result of this year’s audit, a number of further changes will be made, such as:
- Cleaning of rooms and equipment will be reflected on each diary.
- Fridge checking will be allocated to an available clinician each day to ensure no days are missed.
- Occupational standards around staff vaccinations will be updated with regards to increased MMR infections within the UK. Staff immunisations status will be check and any out of date immunisations will be offered.
An audit on Minor Surgery was discussed with the Practiced Manager on 8/9/23
No infections were reported for patients who had had minor surgery at St Paul’s.
The Surgery plan to undertake the following audits in 2023
- Triannual Infection Prevention and Control audits
- Minor Surgery outcomes audit
- Domestic Cleaning 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.
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.
Other examples:
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.
Toys: We have no toys in the practice
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. Some of our sinks do not meet the latest standards for sinks but we have removed plugs, covered overflows and reminded staff to turn of taps that are not ‘hands free’ with paper towels to keep patients safe. We have also replaced our liquid soap with wall mounted soap dispensers to ensure cleanliness.
Training
All our staff receive annual training in infection prevention and control. This is done annually via Clarity TEAMNET (e-learning). Our IPC Lead attends Triannual IPC forums.
Policies
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 more frequently as current advice, guidance, and legislation changes. Infection Control policies are circulated amongst staff for reading and discussed at meetings on an annual basis.
Responsibility
It is the responsibility of everyone to be familiar with this Statement and their roles and responsibilities under this.
Review date
September 2024
Responsibility for Review
The Infection Prevention and Control Lead and the Practice Manager are responsible for reviewing and producing the Annual Statement.
Lucy Rogers and Philip Heiden
Practice Nurse and Practice Manager
For and on behalf of St Paul’s Surgery