Annual Infection Control Statement
Forest House Surgery
25 Leicester Road, Shepshed. LE12 9DF
4.2.2024
Purpose
This annual statement will be generated each year in February, 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.
Forest House Surgery Infection Prevention and Control Team
IPC Lead (GP Partner) - Dr Joanne Watson
Practice Nurse – Tracey
Administrator – Louise
Cleaning Team- Sangita, Grace and Carol.
We follow The Code of Practice for GP Practices using the National Standards of Healthcare, Cleanliness in General Practive
Policies
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:
- Antimicrobial stewardship
- Aseptic technique
- BBVs (Blood-borne viruses)
- C. difficile (Clostridioides difficile)
- CJD (Creutzfeldt-Jakob disease)
- Hand hygiene
- Invasive devices
- MRGNB, including CPE
- MRSA
- Notifiable diseases
- Outbreaks of communicable disease
- Patient placement and assessment for infection risk
- PPE (Personal protective equipment)
- PVL-SA (Panton-Valentine Leukocidin staphylococcus aureus)
- Respiratory and cough hygiene
- Respiratory illnesses
- Safe disposal of waste, including sharps
- Safe management of blood and body fluid spillages
- Safe management of care equipment
- Safe management of linen, including uniforms and workwear
- Safe management of sharps and inoculation injuries
- Safe management of the care environment
- Scabies
- Specimen collection
- SICPS and TBPs (Standard infection control precautions and Transmission based precautions)
- Venepuncture
- Viral gastroenteritis/Norovirus
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.
Infection prevention audits
Forest House Surgery decided to update the Infection Contol Prevention policies in 2023 and following the National Standards of Healthcare Cleanliness in General Practice 2021 Guidance. This has required a period of education, retraining and planning to implement before we could move forward on this. Old policies have been archived and new polices written and implemented for January 2024. Cleaning schedules and audits will follow the Guidance over 2024.
Forest House Surgery team have engaged throughout all the clinical and non clinical teams to assist the cleaning team with this new guidance, as the whole team endeavour to always protect our patients from any infection risk.
The IPC team has now been joined by an administator to help schedule the cleaning plans for different areas within the practice, perform inspections and audits as detailed in the guidance.
A period of transition from old to new is still taking place, but from 1.3.2024 the new cleaning schedules will be working throughout the practice.
Internal audits conducted covering the year 2023
- Annual Infection Prevention and Control Audit Tool of Compliance
Clinical Procedure Audits
- Post procedure infection rates for Contraceptive Implant Fittings/removals/replacements
- Post procedure infection rates for Contraceptive Coil fittings/removal/replacements.
- Post procedure infection rates for Minor Operations.
- Post procedure infection rates for Ear Syringing Procedures
Vaccine Audits
- Vaccine Fridge Temperature Logs Audit
- Vaccine Cleaning Logs Audit
- Cold Chain Compliance Audit
Practical Activity Audits
- Hand washing Audit
- PPE Knowledge Audit
- Sharps Bin Safety Audit
- Privacy curtain cleaning or changes
- Hand Sanitiser expiry date log Audit
- Room Cleaning log Audit
- Clinical Waste Audit
Significant Events in 2023 relating to IPC
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 in 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 which 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 at practice 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 Three significant events raised which related to infection control.
Zero complaints made regarding cleanliness or infection control.
- Cold Chain Breach of Fridge containing vaccines. A fridge plug was switch off accidently and not detected until staff returned into the building the following day. Fridge thermometer readings were taken and confirmed a cold chain breach had occurred. Staff and practice manager followed the practice policy. The relevant confirmation was gained from the vaccine manufacturers that vaccines were still able to be administered without a clinical compromise, but patients would need to be informed they were off licence.
- Event was accidental. Plug had a sign near it “stating FRIDGE DO NOT TURN OFF”
- All staff involved knew their responsibilities relating to the cold chain breach and immediate and correct procedures followed.
- No harm occurred.
- There was no action from this event as it was human error, but this event did raise everyones awareness of policy and act as a training exercise for correct procedure.
- Ear Syringing Audit to assess rate of otitis externa or other ear infection occuring within 4 weeks of ear syringing. Annual Audit revealed an infection rate of 7%. This was too high to continue providing this service, without a full investigation and retraining of staff in this procedure.
- The service was withdrawn with immediate effect and ICB informed.
- This highlights that the practice maintains high standards of care and will act in the patient’s best interests if there is a concern relating to potential harm occuring.
- Cold Chain Breach-A delivery of vaccines from the supply chain were handed to reception staff, the staff member did not take the vaccines immediately to the nursing team as per policy but put them down in reception. There was a short time delay before they reached the fridge.
- Staff and practice manager followed the practice policy. The relevant confirmation was gained from the vaccine manufacturers that vaccines were still able to be administered without a clinical compromise, but patients would need to be informed they were off licence.
- Event was accidental.
- All staff involved were reminded of their responsibilities relating to the cold chain breach and immediate and correct procedures were followed.
- No harm occurred.
There was no action from this event as it was human error, but this event did raise everyones awareness of policy and act as a training exercise for correct procedure.
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.
- Temperature Control Monitoring for Legionella risk
- COSHH
- Privacy curtain cleaning or changes
In the next year, the following risk assessment will also be reviewed:
Clostridium Difficile cases from Antibiotic prescribing within FHS.
Training
In addition to staff being involved in risk assessments and significant events, at Forest House Surgery all staff and contractors receive IPC induction training on commencing their post. Thereafter, all staff receive refresher training with changes in policy or role or every three years.
Various elements of IPC training in the previous year have been delivered at the following times:
Bluestream individual learning, Staff inductions, PLT November 2023
Signed by Dr Joanne Watson, For and on behalf of Forest House Surgery