In line with the Department of Health, The Health and Social Care Act 2008: Code of Practice on Prevention and Control of Infection and its Related Guidance (2015), the practice annual statement will be generated each year.
It will summarise:
- Any infection transmission incidents and any action taken (these will have been reported in accordance with our Significant Events Report procedures).
- Details of any infection control audits undertaken, and actions taken.
- Details of any infection control risk assessments undertaken.
- Details of any staff training
- Any review and update of policies, procedures, and guidelines.
- Update on Covid-19 measure
The report demonstrates the commitment of Railway Medical Group to deliver high quality and safe care to patients and uses effective prevention and control of infection measure to ensure the safety and well-being of patients, staff and visitors.
The lead for infection control is Lead Practice Nurse Anna Mitchinson supported by Healthcare Assistant Debbie Nget.
Infection transmission incidents
There have been no reported significant events of transmission of infections in the last 12 months. However, the following incidents were logged:
1)Out of date wound swab was used, this was picked up by the lab and apology issued to patient and rectified, no delay in treatment. Staff reminded to check expiry dates when stocking up rooms and before using
2) Needlestick injury during vaccination clinic, Practice needlestick policy was followed. As incident occurred with clean needle there was no infection risk and no action needed. The incident was discussed at clinical team meeting and learning noted.
3) Incomplete Hepatitis B vaccination of new clinical member of staff, when identified staff member was stopped from doing venepuncture and injections until vaccinated.
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 Practice Team meetings and learning is cascaded to all staff.
Infection control Audits
The practice is audited quarterly by external auditors against the national standards of healthcare cleanliness. In the last 12 months all sites have achieved the maximum 5 stars with no key areas of concern.
An annual wate management audit is performed as well as internal audits on cleanliness, sharps bins, privacy curtains, aseptic technique, hand hygiene and cold chain (for safe storage and handling of vaccines).
Infection Control Risk Assessments
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 Infection Prevention and Control risk assessments were reviewed:
Blood borne virus exposure
Needles/Sharps injuries
Offsite consultation with patients
Cleaning up spillages of bodily fluids
Staff training
All staff receive training in Infection Prevention and Control appropriate to their job role including general IPC, clinical waste management, hand hygiene, personal protective equipment (PPE), safe use and disposal of sharps, risk management and sepsis awareness.
In the last 12 months the Practice has also had a face-to-face infection prevention and control education session provided by the local Acute Trust IPC nurse.
Infection prevention and control policies
IPC policies and procedures are reviewed annually and ongoing as current practices and guidance changes.
Policies relating to Infection Prevention and Control are available to all staff and are reviewed in line with the Infection Control inspection and are amended on an on-going basis as current advice, guidance, and legislation changes.
Infection Control policies are available to all staff on the staff platform, GP Teamnet, and communicated to staff when updates or new policies are needed to be read and actioned or circulated amongst staff for reading. These are discussed at clinical and non-clinical meetings.
Update on Covid 19 measures
Through out the covid pandemic Railway Medical Group followed local and national guidance to ensure safe environment for patients, staff and visitors.
The routine use of masks for patients and staff has discontinued. Patients can still opt to wear a mask or face covering if desired and request for the clinician to wear one as well.
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 embed the National Standards of Healthcare Cleanliness into our day to day working and will continue to have quarterly audits.
To be reviewed June 2025