Infection Control Annual Statement


This annual statement will be generated annually 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. 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 staff training; and
  • Any review and update of policies, procedures and guidelines.

Infection Prevention and Control (IPC) Lead

Testvale Surgery has a Lead for Infection Prevention and Control: Sister Angela Palmer

The IPC Lead is supported by our Treatment Room lead doctor: Doctor Andrew Robertson

Sister Palmer attends the three IPC Lead training courses each year and feeds back and updates staff at the practice. The last meeting occurred in September 2018 and the next will take place in March 2019. This enables the practice to keep updated on infection prevention practice.

Infection Transmission Incidents (Significant Events)

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. Each significant event is registered by the staff member identifying the event and logged into DATIX, a software programme which the surgery uses to keep a record and share events.

All significant events are reviewed in the quarterly significant event meetings, as well as every six months at Partners meetings. The learning from these meetings is cascaded to all relevant staff and West Hampshire CCG where required.

In the past year, there has been one incident relating to infection control which has been investigated thoroughly by the practice including external review.

Infection Prevention Audit and Actions

The practice has an up to date Infection Prevention and Control Policy, developed by West Hampshire CCG and which has been approved for use in General Practice.

The Annual Infection Prevention and Control audit was completed by Sister Angela Palmer in conjunction with the Practice Manager in April 2019. As a result of the audit, the following issues were been identified as requiring additional oversight:

  • Revision to the domestic cleaning schedule to ensure high risk rooms were being cleaned more methodically;
  • De-cluttering of all clinical areas to aid cleaning and improve infection control;
  • In addition to annual equipment calibration, a review of all clinical areas to remove and replace any broken equipment;
  • Continue the programme of chair replacement in the waiting room areas;
  • Changes to the cleaner’s cupboards to ensure items can be stored off the floor;
  • Work on anti-microbial prescribing to improve the practice status as an outlier against other similar sized practices;
  • Improvements to the cold chain storage processes;

These issues will be tackled over the next twelve months to ensure continual improvement in regard to infection control.

Testvale Surgery plan to undertake the following audits in 2019/20:

  • Phlebotomy audit
  • Infection Control audit
  • Domestic cleaning audit
  • Anti-microbial action plan

Risk Assessments

Risk assessments are carried out so that best practice can be established and then followed. In the last year the following risk assessments were carried out / reviewed:


  • Legionella (Water) Risk Assessment: The practice continued work in relation to the water safety risk assessment to ensure that the water supply does not pose a risk to patients, visitors or staff. This has included adding water testing to our existing controls, as well as insulating water tanks and annual disinfection of the water supply;
  • Annual staff competency reviews have been introduced for staff members undertaking phlebotomy as a result of the phlebotomy audit;
  • Immunisation: The practice takes part in the National Immunisation campaigns for patients and offer vaccinations in house and via home visits to our patient population;

As part of our infection control policy, the practice has instigated quarterly in-house inspections of the cleaning regime to identify areas of good practice, as well as areas to improve on.


All our staff receives annual training in infection prevention and control. Online mandatory training is also available, which includes infection control for any new staff members, or those missing the face to face taught updates.

The Infection Control Lead attends the quarterly Infection Control and Practice Nurse Meetings run by West Hampshire CCG.


The practice uses the West Hampshire CCG Infection Control Policy. All Infection Prevention and Control related policies are in date for this year. There are no infection control related policies which are currently being updated.

Policies relating to Infection Prevention and Control are available to all staff and are reviewed and updated by West Hampshire CCG every three years or when advice, guidance and legislation changes. All policies and procedures are available to staff members on the desktop of each practice computer, so can be readily accessed if required.

Responsibilities and Review Date

It is the responsibility of each individual to be familiar with this Statement and their roles and responsibilities under this. The next review will take place in April 2020.

Angela Palmer, Nurse Practitioner

For and on behalf of Testvale Surgery