Infection prevention and control (IPC) Annual Statement 2022

Infection prevention and control (IPC) Annual Statement 2022

March 2022 – March 2023

In line with the Health and Social Care Act 2008: Code of practice on prevention and control of infection (July 2015) and its related guidance, this Annual Statement will be generated each year.  It will summarise:

  • Any infection transmission incidents and any lessons learnt and action taken
  • Details of any infection prevention and control (IPC) audits undertaken and any subsequent actions taken arising from these audits
  • Details of any issues that may challenge infection prevention and control including risk assessment undertaken and subsequent actions implemented as a result
  • Details of staff IPC training
  • Details of review and update of IPC policies, procedures and guidance
  • To highlight priorities for the upcoming year.

Infection control lead

The Infection Control Lead will enable the integration of Infection Control principles into standards of care within the practice, by acting as a link between the surgery and Leicester, Leicestershire and Rutland Infection Control Team. They will be the first point of contact for practice staff in respect of Infection Control issues. They will help create and maintain an environment which will ensure the safety of the patient / client, carers, visitors and health care workers in relation to Healthcare Associated Infection (HCAI).

The Infection Control Lead will carry out the following within the practice:

  • Increase awareness of Infection Control issues amongst staff and clients
  • Help motivate colleagues to improve practice
  • Improve local implementation of Infection Control policies
  • Ensure that practice based Infection Control audits are undertaken
  • Assist in the education of colleagues
  • Help identify any Infection Control problems within the practice and work to resolve these, where necessary in conjunction with the local Infection Control Team
  • Act as a role model within the practice
  • Disseminate key Infection Control messages to their colleagues within the practice

Practice Infection Control Lead: HCA and Dr Asiya Maula

Cleaning and Decontamination Lead: Fatema Contractor

Significant events

There have been no significant events reported regarding infection control issues in the period covered by this report.

Audits / Risk assessment

The following audits/ assessments were carried out in the practice

  • Infection control annual audit – March 2022
  • Handwashing Audit
  • LLR PCL Site review
  • Infection Control Risk assessment
  • Environmental cleaning audit – completed by ServiceMaster
  • Policy for Reduction of Risk from Legionella reviewed
  • Personal Protective Equipment (PPE) Policy reviewed
  • Policy for the Isolation of Patients reviewed
  • Sharps injury Flow chart review
  • Prescribing Audit
  • Control of legionella policy and procedures reviewed
  • Waste audit trail
  • Vaccine audit


Audit Key findings

  • Infection control audit
    • IP findings communicated to the team through meetings and newsletter.
    • Rooms are clean, clutter free and fit for purpose.
    • Waste is segregated and secure at all times.
    • PPE available in all clinical rooms.
    • Single use items are available and used as single use.
    • All equipment is cleaned between patient uses and evident on inspection.


  • Prescribing Audits
    • Appropriate prescribing seen for antibiotics following local LMSG guidelines


  • Hand hygiene audit
    • Good compliance and awareness of hand hygiene policy
  • Cold Chain policy


  • Control of Legionella Policy
    • Hot and Cold water checks and maintenance completed regularly
    • Risk of legionella contained
    • All initial checks and system sterilisation in place

Staff training

Staff complete annual infection control training through the blue stream training portal, this is renewed annually and audited through the blue stream module. Currently 80% of the expected 100% of staff have completed this training within the last 12 months, with 100% have completed some form of infection control training in the last 24 months.

Acknowledgement is made that The Health Suite has been rapidly expanding, having only opened in August 2020 with lots of new staff, infection control training should be completed within the first 3 months of joining the company. New staff receives an induction pack which includes new login for blue stream training portal.

Due to recruitment and new staff NOT all staff have attended Infection Control refresher training in the last 1 year. Both infection Control Leads for the Practice have attended Infection Control training in the last year.

Policies, protocols and guidelines

The Policies below have been updated this Year. They are reviewed annually or earlier when appropriate due to changes in regulations and evidence based guidance.

  • Safe Handling and Disposal of Sharps
  • Prevention and Management of Occupational Exposure to Blood and Body Fluids (including sharps injuries)
  • Handling general and clinical waste
  • Packaging and Handling of Specimens
  • Isolation of Infective Patients, including reporting to HPA/LA
  • Environmental Cleaning
  • Uniform Policy / Dress Code
  • Antimicrobial Prescribing audits

Priorities and key points for the next 12 months

  • Check staff immunisation status.
  • Calibrate all equipment.
  • Check record of water temperature checks ensure this is done weekly for five minutes each time.
  • Ensure Administration team clean the samples box daily.
  • BP cuff in surgical suite to be changed to wipe able.
  • Ensure all staff are bare below the elbow whilst in clinical areas.
  • Ensure home visiting bags are clean, drugs are checked, PPE is available, sharps bins are in date.
  • Apron holders are provided in all clinical areas.
  • Pillows are of impervious material to ensure effective cleaning can be achieved.
  • Provide wipes for baby changing area.
  • Are Reception staff asking for patient’s infection status?
  • Ask Service Master if cleaners have a record of immunisation status to be able to clean in health care settings.
  • Wall mount alcohol gel.
  • Toilet roll holders to be enclosed holders.
  • Hand washing signs to be removed.
  • All signs to be laminated and placed on a board.
  • Clean and clear the external bin area.
  • Velour chairs to reupholster to impervious material.
  • Keep a record of all vaccines delivered, type of vaccine, quantity, expiry date and batch number.