Purpose
This annual statement will be generated annually 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 Bridgemary Medical Practice has 1 Lead for Infection Prevention and Control: Elizabeth Rudd, Practice Nurse
The IPC Lead is supported by: Dr Catherine Bayliss
Elizabeth Rudd (Lizzie) attends IPC Lead training courses at least annually and keeps updated on infection prevention practice by attending monthly IPC leads meetings with IPC ICB (26/9/24)
IPC meeting one to one with Viv O’Connor on 23/9/24 to discuss specific actions for BMC
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 clinical meetings and learning is cascaded to all relevant staff.
In the past year there has been 0 significant events raised that related to infection control.
Infection Prevention Audit and Actions
The Annual Infection Prevention and Control audit was completed by ER in November 2023
As a result of the audit, the following things have been changed in BMC
- ER has been in contact with Charmaine Donnelly IPC facilitator for surgery walk round
- PM to amend IPC lead job description
The environmental cleanliness audit was undertaken in November 2023
As a result of the audit, the following things have been changed;
- Communications to clinicians to remind them to keep their rooms tidy, de clutter desks and clean environment as per cleaning schedule in rooms
- Due to there being cupboard space only for cleaning equipment which is not big enough, the PM has plans to create a room for this in the practice.
An audit on vaccine storage was undertaken by ER in September 2024
As a result of the audit, we have discussed doing quarterly vaccine stock and vaccine fridge temperature checks which will be fed back to IPC team
An audit on clinical waste disposal sent by Anenta was performed in July 2024- there was satisfactory results from this.
The audit on sharps handling and disposal was done in November 2023
As a result of this audit the following actions were taken
- Posters on correct clinical waste and sharps disposal were put up in all clinical rooms
- A review on numbers and types of waste bins and labelling of such is being done by the PM
- Communication to all staff on keeping safety lids closed between use of sharps boxes
The BMC plan to undertake the following audits in the following year
- Annual Infection Prevention and Control audit -parts 1,2 and 3 to be completed
- Legionella risk assessment
- Domestic Cleaning audit
- Aseptic non touch technique audit
- Antibiotic prescribing
- Ventilation risk assessment
- Anenta waste management duty of care 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:
Asbestos: medium risk
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. There is monthly water testing carried out by Immerse Water Company.
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.
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.
Training
All our staff receive yearly e-learning training in infection prevention and control which is monitored on TeamNet.
Elizabeth Rudd has undertaken specialist training in infection prevention and control in July 2023 at a virtual training session by Wessex LMC
ER to attend IPC link meetings and communicate with the IPC nurse facilitator at ICB, in order to keep updated
ER to consult monthly with the IPC website for national updates
Policies
All Infection Prevention and Control related policies are in date within the last 12 months
However, all of our policies are going to be reviewed and updated in line with national and local guidelines after a change in management this year at BMC and also changes within the ICP at HIOW ICB team
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 available for all staff to read on Team Net and discussed at meetings on an annual basis.
Responsibility
It is the responsibility of each individual to be familiar with this Statement and their roles and responsibilities under this.
Review date: 01/09/25
Responsibility for Review
The Infection Prevention and Control Lead and the Practice Manager are responsible for reviewing and producing the Annual Statement.
Elizabeth Rudd RGN
Practice Nurse
For and on behalf of the Bridgemary Medical Centre
IPC contacts:
IPC team HIOW ICB- 0870 3156601