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Infection Control Statement
Infection Control Annual Statement 2025/2026
Purpose
The annual statement will be generated each year. It will summarise:
- Any learning connected to cases of C. difficile infection and Meticillin-resistant Staphylococcus aureus blood stream infections and action undertaken.
- The annual infection control audit summary and actions undertaken.
- Infection Control risk assessments and actions undertaken.
- Details of staff training (both as part of induction and annual training) with regards to infection prevention & control.
- Details of infection control advice to patients.
- Any review and update of policies, procedures, and guidelines.
Background:
St Bartholomew’s and Hollow Way Medical Practice, Lead for Infection Prevention /Control is Kathleen Moura, role Lead Practice Nurse, who is supported by Chris Taylor/ Samantha Rahim, role Practice Manager/ Nurse Administrator.
This team keeps updated with infection prevention & control practices and share necessary information with staff and patients throughout the year.
Significant events:
Detailed post-infection reviews are carried out across the whole health economy for cases of C. difficile infection and Meticillin Resistant Staphylococcus aureus (MRSA) blood stream infections. This includes reviewing the care given by the GP and other primary care colleagues. Any learning is identified and fed back to the surgery for actioning.
This year the surgery has been involved in 0 C. difficile case reviews and 0 MRSA blood stream infection reviews.
Audits:
Detail what audits were undertaken and by whom and any key changes to practice implemented as a result
Infection Prevention Control and Efficacy
- Date: March 2025, June 2025, September 2025 and January 2026
- Auditor/s: Sam Rahim
- Key changes: Detailed report created to ops manager and practice manager of issues that may increase infection risk. Emails sent to all staff about infection control policies updates. Partners will be looking at isolation room and patient placement policy.
Hand Hygiene
- Date: March 2026
- Auditor/s: Sam Rahim, Manuela Franscesconi, Liz Knight, Jennifer Stone and Kathleen Moura
- Key changes: Staff aware of the importance of handwashing. Yearly hand washing audit carried out.
ANTT
- Date: August 2025 and March 2026
- Auditor/s: Kathleen Moura
- Key changes: Trays provided for clean wound procedures to be used as aseptic field. As a green practice this produces less waste. Trays cleaned with clinell wipes pre/post use. For aseptic wounds dressing packs are available.
National Standards of Healthcare Cleanliness Technical
- Date: March 2026
- Auditor/s: Kathleen Moura
- Key changes: 95% for main site (Manzil way). There’s room for improvement, cleaning issues reported to ops manager
Infection Control Risk Assessments:
Regular Infection Control risk assessments are undertaken to minimise the risk of infection and to ensure the safety of patients and staff. The following Infection Control risk assessments have been completed in the past year, and appropriate actions have been taken:
- COVID-19 outbreak
- Provision and cleaning of toys
- Control of substances hazardous to health (COSHH)
- Disposal of waste
- Healthcare-associated infections (HCAIs) and occupational infections
- Minor surgery
- Sharps injury
- Use of personal protective clothing/equipment
- Risk of body fluid spills
- Legionella risk assessment
- Buildings and facilities that do not meet IPC best practice
NB – only list risk assessments that have been completed in the past 12-months & ensure there is evidence of actions taken as a result (as the CQC may ask to see these documents). List any Cold Chain events and actions taken.
Staff training:
No. 8 new staff joined this Medical Centre/Surgery in the past 12-months and received infection control, hand-washing, and donning and doffing training within 12-months of employment.
54% of the practice patient-facing staff (clinical and reception staff) completed their annual infection prevention & control update training online.
68% of the practice non-patient-facing staff completed their 3-yearly/annual infection prevention & control update training.
The IPC nurse/practitioner attended training updates for their role. Training is provided by the BOB ICB Webinars.
Infection Control Advice to Patients:
Patients are encouraged to use the alcohol hand gel/sanitiser dispensers that are available throughout the Medical Centre/Surgery. Additional IPC measures on hands, face, space have been implemented due to the COVID-19 Pandemic.
There are posters in the Medical Centre and information on website available regarding:
- MRSA
- Chickenpox & shingles
- COVID-19
- Norovirus
- Influenza
- Recognising symptoms of TB
- The importance of immunisations (e.g. in childhood and preparation for overseas travel)
The importance of immunisations (e.g. in childhood and preparation for overseas travel).
Policies, procedures, and guidelines.
Documents related to infection prevention & control are available to all and reviewed in line with national and local guidance changes and are updated 2-yearly (or sooner in the event on new guidance).