Infection Prevention and Control (IPC) Annual Statement 2023-2024

This practice is committed to the control of infection within the building and in relation to the clinical procedures carried out within it. This statement has been produced in line with the Health and Social Care Act 2008 and details the practice’s compliance with guidelines on infection control and cleanliness between the dates of 01.01.2023 and 01.01.2024.

IPC lead for the practice is Angela Winstone

IPC deputy is Kevin Whomes (Business Manager).

Antibiotic and Sepsis lead: Dr Emma Derbyshire

From 2023, 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 have been no reported significant events regarding infection prevention and control.

Staff Training

All staff have been allocated annual IPC training in 2022, level one for non-patient facing staff and level 2 for clinical staff. As of March 2024 our staff have a 100% completion rate for level one and 100% completion rate for level two.

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.


External audit carried out in July 2022, audit report available upon request. We have additionally conducted our own audits for IPC purposes and commit to completing these every 6 months.

Hand Hygiene Audits

Hand Hygiene audits are conducted upon commencement to employment. 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 yearly basis from January 2023 for clinical staff and every 3 years for non-clinical staff. Staff are aware of the importance of hand hygiene in reducing healthcare associated infections. As of March 1st 2024 we are 90% compliant in completing the yearly hand hygiene audit, with those missing being on long term leave.

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.

Safe Management of Rooms and Equipment Audit

Commencing 2023, a 6 monthly audit of room safety, cleaning of rooms and equipment checks.

Cleaning Audits

We now employ 2 cleaners here at the surgery, having previously used a company for this. Our cleaning audits are completed alongside the “Safe Management of Rooms and Equipment Audit”

Minor Procedures Audit

Minor Procedures Audits are conducted . 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:

  • Cold Chain Policy is in place and reviewed July 2023.
  • 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.
  • Fridges have internal temperature readings, secondary thermometers (data loggers) kept inside the fridges and information downloaded weekly.
  • A medical grade Cold Box is available in the practice in case emergency transfer of vaccinations is required.
  • Fridge temperatures continues to be checked once a day and are now recorded electronically on Agilio.

Practice Annual IPC Audit

The last IPC Audit was completed in October 2023. 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.
  • All 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
  • 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:

Staff and patients can choose whether to wear masks, keep social distancing and should always maintain good hand hygiene. We encourage staff and patients to complete a covid test before coming to the surgery if they have covid-like symptoms

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, Fire Risk Assessment and COSHH risk assessment carried out within the last 12 months.

IPC Policy

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