IPC Annual Statement Report

Purpose

This annual statement will be generated each year in May 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 Victoria Medical Centre is Nathalie Allen – Practice Nurse and Kara Brown (Support) – Health Care Assistant

The IPC lead is supported by Kathleen Jewell (PM) and Rachel Gaffney (Deputy 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 2 significant events raised which related to infection control. There have also been 1 complaint made regarding cleanliness or infection control.

b. Infection prevention audit and actions

  • The Practice conducts monthly hand hygiene spot checks on all staff employed by the Practice and audit outcomes are fedback to senior managers and actions taken to improve compliancy. The last audit conducted showed staff are compliant with washing hands and the importance of doing so however there will be campaigns run throughout the year for staff to be further educated on the spread of bacteria and the role in which they play.
  • Deep cleans are conducted for both sites annually in December by Nationwide Cleaning Company. The admin office and staff kitchen at Victoria Medical Centre had multiple stains from spilt liquids, the flooring will be deep cleaned with a specialist machine.
  • Swab samples are taken 3 monthly on services, doors, handles, couches etc. at both sites to test for bacteria. This audit will continue throughout the year and actions taken for any failed swabs.
  • Cleaning audits are conducted monthly by Nationwide Cleaning Company and fedback to management. Some audits were not seen on the day of the audit however Deputy Practice Manager will be liaising with Nationwide to receive all reports and action outcomes.
  • Clinical Curtains are changed every 6 months in all clinical rooms.
  • Facilities such as flooring is monitored regularly to ensure no damage to sterile areas of the buildings
  • Hazardous Waste audits are conducted annually for both sites via Anenta
  • All staff are vaccinated according to their requirements within their roles
  • The Practice Manages outbreaks of infections and has designated contained rooms for hazardous patients
  • The Practice IPC team regularly liaise with the Sussex ICB IPC team and attend regular training days
  • PPE (Personal Protective Equipment) is readily available for all staff
  • Hand sanitising stations located throughout the Practice
  • Staff are trained on safe handling of sharps and correct disposal
  • All staff are trained and reminded on the importance of reporting significant events and learning events, they are stored and recorded on Practice Index and reported on monthly at a senior management internal CQC Compliancy meeting.

The Victoria Medical Practice plan to undertake the following audits in 2024/25

  • Annual Infection Prevention and Control audit
  • Cleaning audit
  • Hand hygiene audit
  • Monthly cleaning standards audit – to be conducted by the cleaning contractor
  • Monthly Waste audit
  • Monthly Sharps bin audit
  • Weekly Cleaning Spot Checks

ICB IPC Contact list

Organization Team Email Telephone Out of Hours Urgent Enquiries
East Sussex Healthcare NHS Trust IPC Team DIS-InfectionControlTeam@nhs.net
NHS Sussex IPC Team Sxicb.infectionprevention@nhs.net
East Sussex County Council Health Protection Team Health.Protection@eastsussex.gov.uk
UKHSA Surrey and Sussex HPT (South East) SE.AcuteResponse@ukhsa.gov.uk

PII Email – phe.sshpu@nhs.net

 0344 225 3861 0844 967 0069

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

  • General IPC risks
  • Staffing, new joiners and ongoing training – Induction programme is in place for all new joiners clinical and non-clinical and they are expected to complete their mandatory training including IPC within the first 2 weeks of employment. A pre-employment health screening is conducted by HR including the requirements for any occupational vaccines/referrals.
  • COSHH
  • Cleaning standards
  • Staff vaccinations – As a practice we ensure that all 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 and Covid vaccinations). We take part in the National Immunisation campaigns for patients and offer vaccinations in house and via home visits to our patient population.
  • Infrastructure changes
  • Sharps
  • Water safety- Legionella: Legionella safety is managed by NANT, an external contractor alongside the Compliance team. All risk assessments, vessel purges, samples etc. are logged on the NANT Portal and any actions are rectified in the time specified. Water temperature checks are conducted weekly and logged on Practice Index and any dead ends are run every Friday to prevent any build up in un-used areas.
  • Clinical 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 also 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.
  • Assistance dogs
  • Training: All our staff receive annual training in infection prevention and control. All clinical and non -clinical staff have completed e-learning training. IPC lead should attend quarterly IPC Lead Practice Nurse forums organised by ICB
  • Hand washing sinks: The practice has clinical hand washing sinks in every room for staff to use.

d. Training

In addition to staff being involved in risk assessments and significant events, at Victoria Medical Centre all staff and contractors receive IPC induction training on commencing their post. Thereafter, all staff receive refresher training annually.

  • All our staff receive annual training in infection prevention and control
  • All clinical and non -clinical staff have completed Practice Index e-learning training.
  • IPC lead should attend quarterly IPC Lead Practice Nurse forums organised by ICB

e. Policies and procedures

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. They are available to all staff via the Practice Index hub which is explained to all staff on their induction to the Practice.

f. Responsibility

It is the responsibility of all staff members at Victoria Medical Centre be familiar with this statement and their roles and responsibilities under it.

g. Review

The IPC lead and Deputy/Practice Managers are responsible for reviewing and producing the annual statement.

This annual statement will be updated on or before May 2025

Signed by – Kathleen Jewell
For and on behalf of Victoria Medical Centre