Practice Policies
Infection Control Annual Statement August 2023 – August 2024
NHS Hampshire and Isle Of Wight
Purpose
This annual statement will be generated each year in August 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 Odiham and Old Basing Surgery has two Leads for Infection Prevention and Control: Juliette Williams (GP Partner) and Holly Kindred (Practice Nurse Team Lead).
The IPC Lead attends the ICB IPC Forums quarterly and cascades any information back to the various teams within the 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 quarterly clinical meetings and learning is cascaded to all relevant staff.
In the past year there have been no significant events raised that related to infection control.
Infection Prevention Audit and Actions
The Annual Infection Prevention and Control audit was completed by Holly Kindred in November 2023.
As a result of the audit, the following things have been changed in Odiham and Old Basing Surgery:
- Introduction of yellow tiger stripe waste bags, alongside orange clinical waste bags. Additionally ensuring all clinical waste is labeled with origin and date.
- Domestic Cleaning review – worked with cleaners to ensure compliance at both sites.
- Refurbishment plan updated and rooms undergoing scheduled maintenance and upgrades.
- Carpets removed from waiting area and corridors in Odiham site, changed to linoleum.
An audit on Minor Surgery was undertaken by Holly Kindred in August 2024.
One infection (September 2023) was reported following procedures at the Odiham and Old Basing Surgery.
As a result of the audit, the following learning points have been shared:
- Wounds on the anterior shin in young people are more prone to wound dehiscence and potential infection - skin might be under more tension for closure of wound.
The practice has not changed minor surgery procedures as this infection was considered to be unavoidable.
An audit on hand washing was undertaken in November 2023. This was discussed at the nurse team meeting in December as the findings affected this team.
The Odiham and Old Basing Surgery plan to undertake the following audits in 2024/2025:
- Annual Infection Prevention and Control audit
- Minor Surgery outcomes audit
- Domestic Cleaning audit
- Hand hygiene 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. A formal Legionella assessment was performed in June 2023 and certification issued for both premises. The next assessment is due in June 2025. Rooms not in regular use have the tapes flushed on a weekly basis as per IPC guidelines.
Immunisation: 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, COVID). 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. This is monitored on TeamNet to remind staff of dates for change and ensure compliance.
Toys: NHS Cleaning Specifications recommend that all toys are cleaned regularly and we therefore provide only wipeable toys in consultation rooms. These are wiped clean after each use using clinell wipes, and stored out of sight so only used with a clinician present who then takes the responsibility of cleaning it.
Cleaning specifications, frequencies and cleanliness: We have updated the cleaning plan and cleaning audits in line with the guidelines provided by the IPC Link. 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. The National colour coding of cleaning materials is used for each area within the Premises. We aim to have a cleaning specification and frequency policy poster in the waiting room, to inform our patients of what they can expect in the way of cleanliness, by 2025.
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, and reminded staff to turn of taps that are not ‘hands free’ with paper towels to keep patients safe.
Training
All our staff receive annual online e-learning training in infection prevention and control, via TeamNet. All staff, clinical and non-clinical, complete the Level 2 Infection Control module.
Dr Juliette Williams has undertaken specialist training in minor surgery and joint injections.
Dr James Carter has undertaken specialist training in joint injections.
Physiotherapist Russel Cruz has undertaken specialist training in joint injections.
Policies
The following policies are currently being updated:
- Infection Control Policy & Standard Precautions
- Infection Control Policies – for clinical conditions and contagious illness
- Contagious Illness Policy and Communicable Infections Policy
- Cleaning Plan and Clinical Waste Protocol
- Decontamination and Disinfection Policy
- Medical Procedures Competency and Aseptic Technique
- Occupational Health Protocol
- Precautions in the Care of the Deceased Policy
- Specimen Handling Protocol
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.
Responsibility
It is the responsibility of each individual to be familiar with this Statement and their roles and responsibilities under this.
Review date
August 2025
Responsibility for Review
The Infection Prevention and Control Leads are responsible for reviewing and producing the Annual Statement, for and on behalf of the Odiham and Old Basing Surgery.
CQC Myth buster Guidance
GP mythbusters: Full list of tips and mythbusters - Care Quality Commission (cqc.org.uk)
