1. Introduction

1.1 Policy statement

In accordance with The Health and Social Care Act 2008, White Horse Medical Practice is committed to the prevention of healthcare associated infection and patient safety is of the utmost priority.  Good management and organisational processes are crucial to ensure that high standards of infection prevention (including cleanliness) are maintained.

Between 15 Oct 20 and 15 Oct 21 this practice ensured that it maintained compliance with the HSCA 2008 for infection control and cleanliness.

An example IPC Annual Statement is detailed at Annex A.

1.2 Status

This document and any procedures contained within it are non-contractual and may be modified or withdrawn at any time.  For the avoidance of doubt, it does not form part of your contract of employment.

1.3 Training and support

The practice will provide guidance and support to help those to whom it applies to understand their rights and responsibilities under this policy.  Additional support will be provided to managers and supervisors to enable them to deal more effectively with matters arising from this policy.

2. Scope

2.1 Who it applies to

This document applies to all employees of the practice, other individuals performing functions in relation to the practice, such as agency workers, locums, and contractors.

2.2 Why and how to them

Infection prevention control is the responsibility of all staff at WHMP.  All personnel are to be fully au fait with the guidance given in the policies associated with this statement. 

The practice aims to design and implement policies and procedures that meet the diverse needs of our service and workforce, ensuring that none are placed at a disadvantage over others, in accordance with the Equality Act 2010.  Consideration has been given to the impact this policy might have in respect to the individual protected characteristics of those to whom it applies.

3. Infection Prevention Control Statement

3.1 Infection Prevention Control (IPC) lead

At WHMP the IPC lead is Tess Mobey, Practice Nurse

3.2 Responsibilities

The IPC lead is responsible for promoting good infection control practice within WHMP they are to ensure that:

• They provide timely advice to colleagues, service users and relatives (where applicable)
• Training is provided regarding the standard principles of infection prevention control, specifically training in hand decontamination, the use of PPE and the safe use of and disposal of sharps (this list is not exhaustive)
• Appropriate supplies of sharps containers, PPE and materials for hand decontamination are available

3.3 Risk Assessments

Risk assessments are undertaken to control risks in the workplace (www.hse.gov.uk).  Between 15 Oct 20 and 15 Oct 21 the following risk assessments were completed: Phelebotomy/needlestick, sharps, sample taking, waste disposal, isolation of pts.

3.4 Recommendations

Following the above risk assessments, the following recommendations were made/actions taken: Policies/Risk Assessments are all on TeamNet.

3.5 Significant events

Significant event analysis (SEA) should act as a learning process for the whole practice, as significant events can reflect good as well as poor practice.  In relation to infection control, this practice has raised no significant events between 15 Oct 2020 and 15 Oct 21.

3.6 Audit

Audit is an essential component of any infection prevention and control strategy (www.worcestershirehealth.nhs.uk).  At WHMP, weekly audits and an annual audit were carried out between 15 Oct 20 and 15 Oct 21.  The key findings of these audits were: incorrect waste bins ie no pedal bins for general waste. Laminated posters were needed for handwashing, sharps, PPE, waste segregation. Carpet cleaning, uniform for contracted cleaners – UKSpring cleaners who follow the NHS national cleaning standards.

The IPC lead can provide further detailed information regarding the audits and subsequent action plans.

3.7 Guidance documentation and policies

WHMP refers to the following guidance documentation and policies  which are related to infection prevent and control:

• Infection Control Policy
• Infection Control Inspection Checklist

3.8 Summary

All staff undertake infection prevention and control training and are committed to maintaining high standards of infection prevention and cleanliness within WHMP.

Regular training, audits and reviews are key to the prevention of healthcare associated infection. 

Annex A – Infection Control Annual Statement

Purpose 

This annual statement will be generated each year in October 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. The report will be published on the practice website and will include the following summary:

• 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 the 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 lead for infection prevention and control at WHMP is Tess Mobey, Practice Nurse

The IPC Lead is supported by Angie Sammut, Practice Manager.

Infection transmission incidents (significant events)

Significant events involve examples of good practice as well as challenging events.

Positive events are discussed at meetings to allow all staff to be appraised of areas of best practice.

Negative events are managed by the staff member who either identified or was advised of any potential shortcoming. This person will complete a Significant Event Analysis (SEA) form that commences an investigation process to establish what can be learnt and to indicate changes that might lead to future improvements.

All significant events are reviewed and discussed in several meetings each month. Any learning points are cascaded to all relevant staff where an action plan, including audits or policy review, may follow.

In the past year there have been 0 significant events raised that related to infection control. There have also been 0 complaints made regarding cleanliness or infection control. 

Infection prevention audit and actions

List all internal audits that have been conducted within the previous year. Discuss the implementation of any audit requirements or shortcomings and how staff are involved to promote high standards of IPC. -Annual audit was completed April 2021.

Detail any projected audit reviews and frequency – weekly audits of clinical areas.

Next full audit due April 2022.

Risk Assessments

Risk assessments are carried out so that any risk is minimised to be as low as reasonably practicable. Additionally, a risk assessment which can identify best practice can be established and then followed.

In the last year the following risk assessments were carried out/reviewed:

• General IPC risks
• Staffing, new joiners and ongoing training
• COSHH
• Cleaning standards
• Sharps
  • Legionella

In the next year, the following risk assessment will also be reviewed:

• Staff vaccinations
• Infrastructure changes

Training

In addition to staff being involved in risk assessments and significant events, at WHMP all staff and contractors receive IPC induction training on commencing their post. Thereafter, all staff receive refresher training.

Various elements of IPC training in the previous year have been delivered which includes hand hygiene training, management of sharps containers.

Policies and procedures

The infection prevention and control related policies and procedures which have been written, updated or reviewed in the last year include, but are not limited, to:

Waste management, needlestick injury, safe use and disposal of sharps, sample handling.

Policies relating to infection prevention and control are available to all staff and are reviewed and updated annually. Additionally, all policies are amended on an ongoing basis as per current advice, guidance and legislation changes. 

Responsibility

It is the responsibility of all staff members at WHMP to be familiar with this statement and their roles and responsibilities under it. 

Review

The IPC Lead PM are responsible for reviewing and producing the annual statement.

This annual statement will be updated on or before 15 Oct 21.

Signed by

Angie Sammut

For and on behalf of White Horse Medical Practice.