Infection Control Statement

Infection Prevention and Control (IPC) Annual Statement 2020-2021

IPC lead for the practice is Cess Quiambao.

IPC deputy is Lesley Kenny (Practice Manager).

Antibiotic and Sepsis lead: Anju Khindri (Pharmacist)

From 2022, this annual statement will be generated in January each year and will summarise:

  • Any infection transmission incidents and actions taken
  • Details of IPC audits/risk assessments undertaken and actions taken
  • Details of staff training
  • Details of IPC advice to patients
  • Any review/update of IPC policies and procedures

Significant Events

There was one significant incident relating to a power cut. Source of failure was external within Hammersmith, identified as a power surge, resulting in the failure. All vaccines fridges were calibrated further to the incident. All vaccines were quarantined until manufactures confirmed vaccines were safe to use, internal data (Temperature) loggers confirmed this. Dr Pritpal Ruprai signed of this document. Imm form report completed & submitted on the intranet portal.

Staff Training

All staff received annual IPC training/updating in July 2020. All staff have been trained in sepsis awareness.

IPC issues/updates are discussed regularly throughout the year in clinical/general meetings.

Staff are encouraged to raise any IPC concerns with the practice manager or IPC lead.


Hand Hygiene Audits

In 2020, Hand Hygiene audits were conducted on a monthly basis to closely monitor compliance. Hand Hygiene Audits returned with 100% compliance in correct technique over the last 12 months. In light of this, hand hygiene audits will be done on a quarterly basis from January 2022. Staff are aware of the importance of hand hygiene in reducing healthcare associated infections.

Waste and Sharps Audits

Waste Audits are conducted on a quarterly basis. The following improvements were undertaken and are now in place further to these audits:

  • A new Policy and Procedure for the Prevention and Management of Body Fluid exposures, including a comprehensive flowchart on Immediate Management of Body Fluid Exposures in place on June 2020.
  • Policy describing waste segregation is updated
  • Bins are labelled as to the type of waste that should be disposed of in them
  • Additional type of sharps bin is in place
  • Clinical and domestic staff are aware of waste segregation procedures was reinforced during staff training

The practice is 100% compliant on its most recent Waste and Sharps Audit.

Cleaning Audits

In 2020, the practice recorded cleaning activities electronically. As part of the practice’s response to Covid-19, a new cleaning checklist for the patient’s waiting area was put in place to bolster the existing infection prevention and control practices.

The practice consistently achieved 100% compliance on cleaning audits in 2020.

Minor Procedures Audit

Minor Procedures Audits are conducted every month. The following improvements were undertaken and are now in place further to these audits:

  • Minor Procedure Safety Checklist is in place and included in patient’s records
  • The following are being closely monitored: Safety Checklist Compliance, Consent Compliance, Patient Record Compliance, Percentage of Histology Sent, Percentage of Malignancy, and Wound Complication Percentage.

There were no wound complication relating to minor procedures in the past twelve months.

Cold Chain Audit

Cold Chain Audits are conducted on a quarterly basis. The following improvements were undertaken and are now in place further to these audits:

  • New Cold Chain Policy in place on September 2020.
  • More staff were trained to order, receive and care for vaccines
  • Vaccines close-to-expiry stock are clearly labelled and vaccines continues to be rotated in date order.
  • An additional vaccine fridge dedicated for flu vaccines was purchased and is now on site to ensure that no more than 66% of the internal volume of all vaccine fridges are filled.
  • New fridge thermometers are in place and secondary thermometers (data loggers) kept inside the fridges continues to be used.
  • A medical grade Cold Box is available in the practice in case emergency transfer of vaccinations is required.
  • Fridge temperatures continues to be checked twice a day and are now recorded electronically on Clarity.

Practice Annual IPC Audit

The last Annual IPC Audit was completed on September 05, 2020. Whilst this is an annual Audit, action points arising from this audit are constantly reviewed during clinical and general meetings.

The following improvements were undertaken and are now in place further to these audits:

  • The practice is now publishing an Annual IPC Statement in their website.
  • Updated Hand hygiene posters from Public Health England are now posted around strategic areas in the practice.
  • Needle-safe devices are now available in the practice.
  • Vertical wipe able blinds are in situ.
  • Disposable couch curtains are in situ.

Covid-19 Response

The following actions have been implemented in response to Covid-19 to keep our staff and patients safe:

  • Strict guidelines for social distancing (1 metre plus mitigating actions).
  • Reception door is closed all the time and is operated by a member of staff to manage patient flow.
  • Seating in the patient’s waiting area are clearly marked to account for sufficient social distancing as per government’s guidelines.
  • Clearly marked routes for patients by dividing the corridor with stickers and arrows to indicate direction.
  • Workstations are to be cleaned before and after use. Minimise sharing of work stations and prevent sharing whenever possible.
  • Staff should make use of PPEs provided as per Public Health England’s guide.
  • Hand sanitiser posters were put up in strategic areas encouraging staff and patients to use.
  • Sanitiser dispenser were put up near the back door for staff/visitors leaving the premises to use.
  • Hard surfaces in consulting and treatment rooms are cleaned before and after each patient visit.
  • Covid 19 risk assessments were done for all staff members.

Actions completed

As indicated in every associated audit above.

Risk Assessments

Risk assessments are performed on a regular basis. We have done the Covid 19 risk assessments for all staff members. Health and safety risk assessment is done on annual basis, Legionella Risk Assessment and COSHH risk assessment done.

IPC Advice to Patients

All eligible patients have been invited for relevant immunisations for example flu, pneumococcal, shingles, whooping cough.

Parents/Guardians are sent regular invites/reminders for childhood immunisations.

IPC Policy

The IPC Policy has been updated and expanded to provide more detailed information.