Annual Statement for Infection Prevention and Control

Purpose

This annual statement will be generated each year in July 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 demonstrates the commitment of Frome Medical Practice to deliver high quality and safe care to registered patients and uses effective prevention and control of infection measure to ensure the safety and well-being of patients, staff and visitors.

It summarises:

• Any infection transmission incidents and any action taken (these will have been reported in accordance with our Significant Event procedure).
• Update on Covid-19 measures.
• Details of any infection control audits undertaken and actions undertaken.
• Details of any risk assessments undertaken for prevention and control of infection.
• Details of any staff training.
• Any review and update of policies, procedures and guidelines

The IPC Lead for the Practice is the Lead Nurse.

Infection transmission incidents

There have been no reported significant events of transmission of infections in the last year. However, the following incidents were logged:

• The lid of a patient sharps bin handed in for disposal came off when transporting it, resulting in a near miss of a needle stick incident. 
• Sharp incorrectly re-sheathed resulting in a needle stick injury.

As there have been near miss incidents when accepting patient sharps bins for disposal that were not correctly closed/assembled, we took the decision to not accept these sharps bins but to direct patient to Somerset Council to arrange collection. 

Significant events (which may involve examples of good practice as well as challenging events) are investigated in detail to see what can be learnt and to indicate changes that might lead to future improvements. All significant events are reviewed in the SEAside meetings and learning is cascaded to all staff.

Infection Prevention Audits

1. Sharps Bin Audit

These audits are undertaken quarterly by the Stock Controller. In the last audit, a total of 44 clinical rooms were audited against 4 standards - compliance in brackets:

Bin correctly assembled

• Oct 22: 98%
• Jan 23: 92%
• April 23: 98%
• July 24: 88.64%

Bin correctly labelled

• Oct 22: 96%
• Jan 23: 94%
• April 23: 79%
• July 24: 100%

Bin in temporary closed position when not in use

• Oct 22: 85%
• Jan 23: 69%
• April 23: 100%
• July 24: 88.64%

Evidence of fortnightly checks

• Oct 22: 87%
• Jan 23: 94%
• April 23: 95%

Bin assembled within last 3 months

• Oct 22: 96%
• Jan 23: 80%
• April 23: 98%

Bin positioned away from patient chair/treatment area

• Oct 22: 98%
• Jan 23: 94%
• April 23: 100%
• July 24: 100%

Total number of rooms compliant

• 32/44 (72.7%)

Any issues are addressed with individuals where possible and are reviewed by the health & safety team. The audit provides moderate to high levels of assurance.

2. Infection Control Room Check Audits

These are undertaken quarterly by the Quality Assurance Officer, and measure effectiveness of clean environment. The most recent audit was completed in June 2024, and rooms were awarded an overall star rating based on specific criteria. A selection of both clinical and non-clinical rooms are audited.

There are a total of 49 rooms used for consultations with patients, therefore the number and specific rooms audited on each occasion will vary. There are a maximum of 8 stars which can be awarded.

Of the 20 clinical areas were audited, the results were:

8 stars ********

• July 2024: 3 rooms

7 stars *****

• July 2024: 7 rooms

6 stars ****

• July 2024: 5 rooms

5 stars ***

• July 2024: 3 rooms

4 stars ****

• July 2024: 2 rooms

The most common reasons for non-compliance were clutter on window-sills/desks and cleanliness of workstation and equipment. Staff are issued with reminders via the IPC bulletin for the need to keep workstations clean and free from clutter. There is an expectation that all staff clean their workstations at the end/start of each shift.

3. Monthly Cleaning Audits

Cleaning Estates & Facilities Cleaning of the whole building is carried out by a cleaning company and maintenance and servicing is managed by the onsite building manager. Cleaning audits are completed by the cleaning company and are reviewed at the health & safety meetings. 

4. External Clinical Waste Audit

A pre-acceptance audit and duty of care audit are carried out and sent Anenta for approval. 

5. Annual IPC Audit

This was completed in March 2024 by the IPC Lead with support from the building manager.

6. Annual Asepsis Technique Audit 

This was completed between February and May 2024 and involved observing the aseptic practice of 6 members of staff. Overall score for aseptic technique procedure was 98% and for competency assessment 100%.

7. Annual IPC Efficacy Audit 

This was completed in Feb 2024 by the building manager and PPE auditor. Overall score was 90% and the target score is 80%.

Risk assessments undertaken for prevention and control of infection

The Practice has updated all risk assessments related to Infection Prevention and Control. 

Risk assessments for safe use of cleaning and disinfectant products which are classified as Control of Substances Hazardous to Health (COSHH) as well as risk assessments for invasive procedures are carried out so that best practice can be established and then followed. Risk assessments are reviewed annually. In the last year the following IPC and COSHH related risk assessments were carried out/reviewed: 

• General COSHH
• Preserv CYT Solution (COSHH)
• Neutral Buffered Formalin (COSHH)
• PDI Sani Cloth (COSHH)
• Spillage Kit Response (COSHH)
• GV Health Urine and Vomit Spill Kit (COSHH)
• Virusafe Spillage Kit (COSHH)
• Health Biohazard Spill Kit (COSHH)
• Clinell Spill wipes (COSHH)
• Respiratory Seasonal Viruses
• Clinical Waste Handling
• Injections
• Needle Stick Injury
• Minor Surgery
• IPC General
• PPE and contact with body fluids
• Aquasonic 100 ultrasound transmission gel (COSHH)
• WD40 aerosol (COSHH)
• Large sharps bins
• Infectious diseases and use of face masks
• Measles outbreak
• Eliminator fogger (COSHH)
• Decisions on decontamination of clinical rooms

Review and update of policies, procedures and guidelines

• Infection prevention and control
• Safe handling of sharps & management of needle stick injuries
• Cleaning 
• Immunisations and vaccinations
• Injections
• Female contraception and sexual health
• Waste management
• Uniform and dress code
• Managing measles outbreaks
• Wound care assessment and leg ulcers

Staff Training

All staff receive training in infection prevention and control appropriate to their job role, including general IPC, clinical waste, hand hygiene, personal protective equipment (PPE), safe use and disposal of sharps, risk management, sepsis awareness. Reminder aids are available for care navigators and clinicians for sepsis, stroke & heart attack symptoms.

Infection Prevention and Control training is assigned to 140 staff. There are different levels of training depending on staff roles and responsibilities.

• Tier 1 – awareness training for all staff. This tier outlines the principles of IPC Practice. It applies to everyone working within health and social care regardless of their role, seniority, grade, and whether or not they interact with patients.
• Tier 2 – for all clinical staff. Will include (but not be limited to) staff such as: Nurses, Doctors, Allied Healthcare Professionals, Healthcare Assistants, Technicians, Cleaning staff, Estates and Facilities staff admin and reception.
• Tier 3 – for senior managers and Infection Control Lead. This tier is applicable to those who for example are managers of a particular area of care and who have responsibility for ensuring safe practice. This Tier is not for IPC practitioners themselves, although people working at Tier 3 would be expected to work with and report to such practitioners to ensure good IPC practice in the local area/environment.

Current level of overall compliance is 87%

All staff with out of date training have been reminded.

Priorities & Objectives for the Coming Year

We continue to work on our annual programme of work based on the 10 criterion of the Health & Social Care Act 2008: Code of Practice on the prevention and control of infections 2015 and related guidance which is a working document that highlights any areas that require further work for the year. We now comply with the National Standards of Healthcare Cleanliness. It is the responsibility of each individual member of staff to be familiar with this Statement and their roles and responsibilities under this.

Review Date

July 2025

Review compiled by

Pernille Johansen (Infection Prevention & Control Lead)