Annual Statement for Infection Prevention and Control (IPC)

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 our 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).
• 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 (Significant Events) and Complaints

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

• Needle stick injury when disposing of a needle. Needle stick procedure followed.

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.

Antimicrobial Stewardship

Antimicrobial resistance (AMR) is a global problem that impacts all countries and all people. The scale of the AMR threat, and the need to contain and control it, is widely acknowledged. 

In addition, the plan has been designed to ensure progress towards the next 20 years vision on AMR, in which resistance is effectively controlled and contained. 

The 3 key aims are:

1. Reducing the need for, and unintentional exposure to, antimicrobials
2. Optimising the use of anitmicrobials
3. Investing in innovation, supply and access

Frome Medical Practice has clear guidelines for prescribing and monitoring prescribing of antibiotics and regular audits are performed. 

We completed 2 Quality Improvement projects in 2025, relating to Quinolone and Co-Amoxiclav prescribing. 

Infection Prevention Audits and Actions: 

1. Sharps Bin Audit

These audits are undertaken quarterly by the Stock Controller. In the last audit, a total of 48 clinical rooms were audited against 4 standards - compliance in brackets:

Bin correctly assembled

• Total number of clinical rooms compliant: 48/48
• % of clinical rooms complaint: 100%

Assembly label completed correctly

• Total number of clinical rooms compliant: 46/48
• % of clinical rooms complaint: 95.83%

Temporary closed position

• Total number of clinical rooms compliant: 35/48
• % of clinical rooms complaint: 72.92%

Away from patient chair

• Total number of clinical rooms compliant: 48/48
• % of clinical rooms complaint: 100%

Total number of rooms compliant

• Total number of clinical rooms compliant: 32/48
• % of clinical rooms complaint: 62.66%

Any issues are addressed with individuals where possible and are reviewed by the health and 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 2025, 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 21 clinical areas audited in June 2025, the results were:

8 stars ********

• June 2025: 3 rooms

7 stars *******

• June 2025: 3 rooms

6 stars ******

• June 2025: 10 rooms

5 stars *****

• June 2025: 5 rooms

4 stars ****

• June 2025: 0 rooms

The most common reasons for non-compliance were clutter on window-sills / desks and cleanliness of workstation and equipment or labelling / temporary closure of sharps bins. Staff are issued with reminders via the IPC bulletin for the need to keep workstations clean and free from clutter and about management of sharps bins. There is an expectation that all staff clean their workstations at the end / start of each shift. The Lead Nurse has attended clinical team meetings to give an infection control update, including management of sharps bins and cleaning of environment. 

3. Monthly Cleaning Audits

Cleaning Estates and 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 and 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 June 2025 by the IPC Lead, with support from the building manager.

6. Annual Asepsis Technique Audit 

This was completed between February and March 2025 and involved observing the aseptic practice of 5 members of staff. Overall score for aseptic technique procedure was 92% and for competency assessment 100%.

7. Annual IPC Efficacy Audit 

This was completed in January 2025 by the building manager and PPE auditor. Overall score was 88% and the target score is 80%.

Clinical Infection Prevention and Control Risk Assessments 

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)
• Sharps bins
• Infectious diseases and use of face masks
• Measles outbreak
• Eliminator fogger (COSHH)
• Decisions on decontamination of clinical rooms
• Hydrex pink (COSHH)
• CoaguChek XS PT control (COSHH)
• Formaspill absorbent COSHH)

Policies

Policies relating to Infection Prevention and Control are available to all staff and are reviewed and updated at least annually and are all amended on an ongoing basis as current advice, guidance and legislation changes. 

IPC related policies and procedures include: 

• Infection prevention and control
• Safe handling of sharps and 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
• Hazardous substances (COSHH) 

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 and sepsis awareness. Reminder aids are available for Care Navigators and clinicians for sepsis, stroke and heart attack symptoms.

Infection Prevention and Control training is assigned to 133 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.

Responsibility 

It is the responsibility of each individual to be familiar with this Statement and their roles and responsibilities under this. 

Priorities and 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. 

Review Date

July 2026

Review compiled by

Pernille Johansen (Infection Prevention & Control Lead)