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 with the support of a GP Partner

Infection transmission incidents

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

• Used needle found on clinic room floor – human error – no injuries – ‘near miss’ incident. Staff have been reminded about the safe use and handling of sharps.

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.

Update on Covid-19 measures

Throughout the Covid pandemic, where clinically appropriate and safe to do so, many consultations were moved to telephone rather than face to face. However as health services have returned to normal business, from the beginning of May consultations have been predominant face to face, unless patients have difficulty in physically accessing the practice.

Throughout 2022 and until spring 2023, as incidence of Covid 19 increased the Practice amended guidance for staff and patients on the use of masks. In March of this year as incidence of Covid transmission declined, following an internal risk assessment and in line with national guidance, routine use of masks for patients and staff were discontinued. Patients can still opt to wear a mask or face covering if desired and request for the clinician to wear one as well.

As of 31st March 2023, staff are no longer required to undertake routine testing using Lateral Flow tests. Staff are recommended to stay away from home if feeling unwell, in line with other infectious illnesses.

Infection Prevention Audits

1. Hand hygiene audit

A routine hand hygiene audit was undertaken over 2 consecutive days in April 2023. Staff were unaware the audit was to take place to ensure results were reliable. The audit measures compliance.

The staff groups audited included the Practice Nurses (PN) and Health Care Assistants (HCAs) who undertake a high proportion of invasive procedures such as blood tests and dressings.  A total 63% of PNs and 72% of HCAs were audited, this was due to working patterns, sickness and annual leave of other staff.

Staff were audited against 8 standards, and both staff groups achieved 100% compliance in all but one standard of ‘bare below the elbow’ – no wristwatches, long sleeves, no stoned rings except a plain wedding band. On this standard 58% of PN and 75% of HCAs were compliant.

Key moments

• Practice Nurses: 100%
• HCAs: 100%

Bare below the elbows

• Practice Nurses: 58%
• HCAs: 75%

Correct HH technique

• Practice Nurses: 100%
• HCAs: 100%

Soap & water vs sanitiser

• Practice Nurses: 100%
• HCAs: 100%

Disposal paper towels

• Practice Nurses: 100%
• HCAs: 100%

Cuts and grazes covered

• Practice Nurses: 100% (NA)
• HCAs: 100% (NA)

FRSM

• Practice Nurses: 100% (NA)
• HCAs: 100% (NA)

Aprons/gloves

• Practice Nurses: 100%
• HCAs: 100%

2. Sharps Bin Audit

These audits are undertaken quarterly by the Stock Controller. A total of 49 clinical rooms were audited against 6 standards - compliance in brackets:

Bin correctly assembled

• Oct 22: 98%
• Jan 23: 92%
• April 23: 98%

Bin correctly labelled

• Oct 22: 96%
• Jan 23: 94%
• April 23: 79%

Bin in temporary closed position when not in use

• Oct 22: 85%
• Jan 23: 69%
• April 23: 100%

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%

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.

3. Infection Control Audits

These are undertaken quarterly by the Quality Assurance Officer and ICPC Nurse, and measure effectiveness of clean environment. The most recent audit were undertaken in March and June 2023, and were awarded an overall star rating based on specific criteria.

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 6 stars which can be awarded.

Of the 15 clinical areas were audited, the results were:

6 stars ******

• March 2023: 8 rooms
• June 2023: 3 rooms

5 stars *****

• March 2023: 4 rooms
• June 2023: 8 rooms

4 stars ****

• March 2023: 2 rooms
• June 2023: 3 rooms

3 stars ***

• March 2023: 2 rooms
• June 2023: 1 room

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 free from clutter. There is an expectation that all staff clean their workstations at the end of each shift.

4. 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 caretaker. Cleaning audits are completed by the cleaning company and are signed off by the health & safety lead.

5. External Clinical Waste Audit

This is carried out each year. An action plan is created and reviewed by the health & safety team.

Risk assessments undertaken for prevention and control of infection

In addition to the information given above in relation to changes to use of PPE post Covid-19 pandemic, 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 risk assessments were carried out/reviewed:

• General COSHH
• Preserv CYT Solution (COSHH)
• Neutral Buffered Formalin (COSHH)
• PDI Sani Cloth (COSHH)
• Spillage Kit Response (COSHH)
• Creightons Pure Touch handgel (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

Review and update of policies, procedures and guidelines

• Infection Prevention and Control
• Safe Handling and Disposal of Sharps
• Cleaning schedule
• Immunisations and vaccinations
• Injection Policy
• Female Contraception and Sexual Health
• Waste Management
• Uniform and Dress Code

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.

Infection Prevention and Control training is assigned to 140 staff. The training requirements set by NHS England Skills for Health for staff working in healthcare have been updated in March 2023. The practice is working with our training providers to ensure the correct training is assigned to each staff group. 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 85%

Safe Use and Disposal of Sharps training is assigned to 80 members of staff, current levels of compliance is 80%

All staff with out of date training have been reminded.

Review and update of policies, procedures and guidelines

• Infection Prevention and Control
• Safe Handling and Disposal of Sharps
• Cleaning schedule
• Immunisations and vaccinations
• Injection Policy
• Female Contraception and Sexual Health
• Waste Management
• Uniform and Dress Code

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. From July we will be working to comply with the National Standards of Healthcare Cleanliness.

From July 2023 Green Machine, our new cleaning contractor, will be complying 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

June 2024

Review compiled by

Virginia Garnett (Infection Prevention & Control Lead)