26.8.25

This annual statement will be generated annually, 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 organisation’s 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 or learning events procedure)

·       Details of any infection control audits carried out 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 The Ridgeway Surgery is Bethan Powell-Hawker, General Practice Nurse. 

The IPC lead is supported by Ella Thompson. Business/Practice Manager. 

a.       Infection transmission incidents (significant events/learning events)

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

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

Negative events are managed by the Business/Practice Manager (BPM). The staff member who either identified or was advised of any potential shortcoming will provide the BPM with a full report of the event. The BPM will complete a Significant Event Analysis (SEA) or Learning Event form on the surgery internal only intranet (TeamNet).  No patient identifiable information will be noted on this system.  This then commences an investigation process to establish what can be learnt and to indicate changes that might lead to future improvements.

All significant events/learning events are reviewed and discussed at several meetings following when they were reported. Any learning points are cascaded to all relevant staff where an action plan, including audits or policy review, may follow.

Since the last IPC Statement on 9.2.2024, there has been 1 significant events/learning event raised which related to infection control. There have not been any complaints made regarding cleanliness or infection control. 

b.       Infection prevention audit and actions

We have undertaken the following Infection Control Audits since our last IPC Statement on 9.2.2024:

External IPC Audit – carried out on 31.07.2024

Conducted by:

Health Protection, Prevention and Improvement Senior Specialist Officer

Quality and Safety: Dudley Place
NHS Black Country Integrated Care Board

Actions were addressed and completed to the satisfaction of the ICB IPC Lead within the time limits set by the audit.  Significant changes made as result of the action plan were:

-       Dani stations fitted in each consulting room

-       Soap dispensers replaced for covered ones

-       Toilet seats replaced

-       Reflooring of consulting rooms programme commenced

-       Daily cleaning schedules issued to all each consulting room

-       Carpet by exits replaced

-       2 chairs and 1 couch replaced

-       Toilet roll dispensers replaced for covered ones

-       General cleaning guidance from the audit, passed onto the cleaning contractors

-       Wipeable chairs in waiting rooms and clinical rooms replaced those that were non-wipeable

-       IPC signage in updated

-       Consulting rooms decluttered and items removed from the floor

Internal IPC audits

Minor surgery room audits – completed monthly
Infection Control annual audit – last completed 26.8.25
Infection Control quarterly audits – last completed 18.7.25
Hand hygiene audit – completed 26.6.25
Cold Chain audit completed 4.2.25
A full audit is completed monthly by the cleaning contractor, Lawrence Cleaning.

Actions from the internal audits:

One medication in a fridge was out of date and needed discarding
Admin staff member given the role of fridge cleaning to relieve pressure on nursing team to do this
Baskets supplied for tall nursing room fridge to store medications. 

c.       Risk assessments 

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

Since our last IPC statement on 9.2.2024, the following IPC related risk assessments were carried out/reviewed:

·       Bodily fluids, blood, vomit and urine

·       Fridge maintenance

·       Legionella

·       COSHH

·       General IPC risks

·       Staffing, new joiners and ongoing training

·       Cleaning standards

·       Privacy curtain cleaning or changes

·       Staff vaccinations

·       Sharps

·       Assistance dogs

d.       Training

In addition to staff being involved in risk assessments and significant events/learning events, at The Ridgeway Surgery all staff and contractors receive IPC induction training on commencing their post. Thereafter, all staff receive refresher training annually.

e.       Policies and procedures

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

Infection Prevention Control (IPC) Handbook v1.1 – updated 20.2.2025
RWM21 Infection Control policy V5.3 –updated 20.2.2025
RWA40 Waste Management (was clinical waste) policy V3.3 – updated 19.3.2025

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. 

f.        Responsibility

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

g.       Review

The IPC leads Bethany Powell-Hawker, Practice Nurse, and Ella Thompson Practice Manager are responsible for reviewing and producing the annual statement.

This annual statement will be updated within 12 months and no later than 31.12.2026.

 

Signed by

Ella Thompson

Business/Practice Manager
For and on behalf of The Ridgeway Surgery