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Purpose of the ‘Annual statement’
The Health and Social Care Act 2008: code of practice on the prevention and control of infection and related guidance requires the Infection Prevention and Control (IPC) Lead to produce an annual statement. This statement should be made available for anyone who wishes to see it, including patients and regulatory authorities and should also be published on the General Practice website.
Introduction
This Annual statement has been drawn up on 05/06/2025 in accordance with the requirement of the Health and Social Care Act 2008: code of practice on the prevention and control of infections and related guidance for Fernbank Surgery. It summarises:
- Infection transmission incidents and actions taken
- IPC audits undertaken and subsequent actions implemented
- Risk assessments undertaken and any actions taken for prevention and control of infection
- Staff training
- Review and update of IPC policies, procedures and guidelines
- Antimicrobial prescribing and stewardship
This statement has been drawn up by:
- Fran Lees - Infection Prevent and Control (IPC) Lead
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.
Issue
Upload all policys relation IPC on Practice Index
Actions
Make aure the 28 policy sin the handbook are loaded onto Practice Index
Date for completion
Ongoing
Person responsible
Sophie Spedding/ Steph Chetter
Progress
Removal of damaged equipment from clinical rooms
To remove chairs or equipment with damage fabrication in accordance with the IPC Policy
Ongoing
Fran Lees and Sophie Spedding
Multiple chairs and unused equipment disposed of March 25
Maintain noticeboards for cleanliness and check posters are laminated
Update cleaning rota responsibilities and make sure actioned by appropriate staff
Ongoing
Sophie Spedding
Implement appropriate isolation and cohorting procedures for patients with infectious diseases.
Both surgeries Lytham and Freckleton have an emergency room set up in the event of illness or isolation for patients with life saving equipment within.
April 2025
Fran Lees and Sophie Spedding
Established from March 2025
Forward plan/Quality improvement plan review date: 17th June 2025
Providing NHS Services
Contact
Fernbank Surgery
Lytham Primary Care Centre
Victoria Street, Lytham
FY8 5DZ
Freckleton Health Centre
Douglas Drive, Freckleton
Lancashire, PR4 1RY
Telephone: 01253 202040