Annual Infection Prevention Control Statement

1. Infection transmission incidents (Significant events)

Provide details of infection transmission incidents (which may involve examples of good practice as well as challenging events), how they were investigated, any lessons learnt and changes made as a result to facilitate future improvements. 

SEA’s Significant Events, describes any unintended or unexpected event, which could or did lead to harm of one or more patients. Any highlighted SEA’s are discussed within meetings, to highlight to staff of the situation. 

Positive events are brought to be discussed at internal meetings and allow staff to be praised highlighting areas of best practice. 

Within the last year we have had 1 compliant with regards to processes of taking blood, as pt felt the TNA should have been wearing gloves, with regards to infection prevention control. Once this was highlighter the lead practice nurse investigated the current regulations, and it found that wearing gloves was not a current requirement for when taking blood. This was discussed and communicated to the patient. The learning outcome for all staff was that they could wear gloves if they wanted too but it is not a requirement to do so.

We will continue to check on any regulation changes that come through updated training in the future. 

2. IPC Audits and actions 

Provide an overview of IPC audit programme as well as examples of good practice and actions taken to address suboptimal compliance.

Infection Prevention Society Audit Tool was completed in March/April 2024 and resulted in the following actions;
Removed books and magazines from waiting room.

• Removed childrens toys from waiting room.
• All patient information laminated on notice boards, which are wipe clean and are included in a cleaning schedule. 
• Curtains are changed in accordance with timeline every 6-12 months. 
• Gloves used are nitrile gloves, as per IPC handbook.
• Meeting with cleaning contractors.
• Measles outbreak and swabs for testing along with isolation protocol.
• Staff up to date with IPC training, with monthly updates provided by IPC lead.
• Wash hands posters in all toilets.
• Sharps box sustainability, up to date with current regulations. 
• Review reception specimen policy – trolley implemented for cleanliness and organisational purposes.
• Cold chain policy in place, when fridge breech took place in 2024 dealt with in accordance with the policy and issue rectified.
• Waste bins for clinical and non-clinical

IPC Audit due to take place in May/June 2025

3. Risk Assessments 

The risk assessment is a systematic process that identifies potential hazards and analyses how they could cause harm. A decision-making tool that helps the surgery to determine how to control or eliminate those risks.

The following have been risk assessed:

• Legionella
• Measles 
• External Cleaning Company – Standard of cleaning

4. Staff training 

In addition to staff being involved in risk assessments and significant events, at Fernbank Surgery all staff receive IPC induction training on commencing their post. Thereafter, all staff receive refresher training annually the level of training is dependent on the staff members role and responsibilities.

Various elements of IPC training within the last 12 months have been delivered via online training supported by:

• Bluestream online Training and Practice Index Hub training 
• 2 yearly Infection control update from lead -  Fran Lees 
• IPC updates via Teams, on a monthly basis

5. IPC Policies, procedures and guidance

Provide details of all policy reviews and updates, together with details of how changes have been implemented.

All policies and procedures relating to Infection prevention and control, that have been implemented at Fernbank Surgery and will continue to be reviewed and updated annually or when required due to differing factors such as legislation changes, guidance or advice. These include but not limited to:

• IPC Handbook
• MMR vaccinations relating to staff, risks considered

6. Antimicrobial prescribing and stewardship

Provide details of all activities undertaken to promote and improve antimicrobial prescribing and stewardship.

• Highlighting antibiotic prescribing to patients, via posters displayed within the surgery.
• Prescribing clinicians undertake an annual prescribing declaration – to ensure we follow best practice and comply with regulations.

Forward plan/Quality improvement plan review date: 17th June 2025