Infection Control Annual Statement 
2016-2017
1.	PURPOSE

In line with the Health and Social Care Act 2008: Code of practice on prevention and control of infection and its related guidance, the Annual Statement will be generated each year in December and will summarise:
•	Any infection transmission incidents and any lessons learnt and action taken as reported in accordance within our Significant Event procedure
•	Details of any infection prevention and control audits undertaken and any subsequent actions taken arising from these audits
•	Details of any issues that may challenge infection prevention and control including risk assessment undertaken and subsequent actions implemented as a result 
•	Details of staff training 
•	Details of review and update of policies, procedures and guidance

2.	INFECTION CONTROL LEAD

The Infection Control Leads are Senior Nurses Sandra Vellacott and Colina Harvey, they are supported by Stephanie Berry, Deputy Practice Manager and Mike Hancock, Cleaning Supervisor.  Infection Control Training was completed on 19th October 2016 which was provided by The Medical Protection Society.

They will be the first point of contact for practice staff in respect of Infection Control issues. They will help create and maintain an environment which will ensure the safety of the patient / client, carers, visitors and health care workers in relation to Healthcare Associated Infection (HCAI). 

The Infection Control Team will carry out the following within the practice:
•	Increase awareness of Infection Control issues amongst staff and clients 
•	Help motivate colleagues to improve practice
•	Improve local implementation of Infection Control policies 
•	Ensure that practice based Infection Control audits are undertaken
•	Assist in the education of colleagues 
•	Help identify any Infection Control problems within the practice and work to resolve these, where necessary in conjunction with the local Infection Control Team
•	Act as a role model within the practice
•	Disseminate key Infection Control messages to their colleagues within the practice 

3.	SIGNIFICANT EVENTS
There has been 1 needle stick injury reported in the period covered by this report.

4.	AUDITS / RISK ASSESSMENT
The following audits/ assessments were carried out in the practice 
•	Infection control annual audit 

Date of risk assessment 19th October 2016
Audit Key findings/ Recommendations / Updates:_
o	The practice needs to produce an annual statement that is available to anyone that requests it.
(this document which will be available on the Practice Website)

o	The practice’s Infection Control Policy is now specific to the Combe Coatsl Practice following amalgamation of Warwick and Waterside Practices.  
(completed)

o	The practice uses a commercial biohazard spill kit; however, the contents are not suitable for spillages of urine. 
(Spill kits for urine and vomit now purchased) 

o	The practice does not have an inventory of medical devices detailing the frequency and method of cleaning each device. 
(Devices are cleaned after each use)

o	The practice has not undertaken a COSHH assessment.
(Completed)
 
o	COSHH data sheets were not available for cleaning products used.
(Situated in cleaning cupboard but not seen by inspector during assessment)

o	The practice uses latex gloves.  A risk assessment has not been undertaken.
(We have both but not seen by inspector during assessment)

o	Staff have not yet been offered the full range of routine immunisations.
(Completed)

o	Some hazardous cleaning agents were stored on work surfaces in clinical rooms.
(Removed)

o	The practice does not have a formal non-clinical triage protocol, which would include specific information to assist reception staff in identifying infections eg chicken pox, norovirus.
(Isolation of Patients Policy now in place)

o	The practice does not have a policy on monitoring antimicrobial usage within the practice.
(Provided on prescribing site)

o	Clinical Waste bags awaiting collection are not appropriately labelled, detailing the name of the practice.
(Completed by SRCL)

o	Patient specimens awaiting collection are occasionally stored in the domestic refrigerator in the kitchen.
(Sample Fridge purchased)

o	The practice was unfamiliar with the current guidance on hand hygiene.
(Completed)

o	Clinical waste bins in some consulting rooms were not lined with the appropriate colour clinical waste bag.  The domestic bin in the kitchen are was open and without a lid.
(Clinical waste bags are now in all clinical waste bins.  New domestic bin purchased)

o	Hand washing sinks are occasionally used for discarding urine samples.
(Incorrect information – this never happens)

o	Some clinical rooms did not have appropriate materials for cleaning the examination couches between patients
(Checklists for supplies are now displayed in all clinical room for HCA’s to complete daily)

o	No audit has been undertaken of infection occurring following minor surgery.
(Now in place)

o	Glucometers which are intended as single patient use devices are reused on multiple patients.

o	No sharps injury first aid poster is displayed.
(Completed)

o	The practice’s approach to antimicrobial use and resistance is not covered in prescribing clinicians’ induction and training

o	Disposable couch roll was stored on the floor in some clinical rooms.
(Removed)

o	Some hand washing sink had plugs in situ
(Removed)

o	Some chairs cannot be easily cleaned as covering is fabric
(To be replaced as funds allow)

o	Not all staff are aware of the current guidance in relation to hand hygiene
(Done)

•	Legionella Management
o	Annual Risk Assessment Completed on 8th September 2017 – no issues.  Checks are completed monthly by practice caretaker. Management training due on 16th October 2017.

•	Vaccine Storage Audit (no current Issues)
•	Hand hygiene audit (no current issues)

5.	STAFF TRAINING
All new members of staff complete Infection Control Training as part of their induction programme.
The nursing team, 1 x GP, Cleaning Supervisor, 1 x Cleaner, Admin Team Leader, 1 x Admin and Deputy Manager completed infection control training October/November 2016.
Admin Staff are due to complete training September/October 2017 via The Blue Stream Academy E-Learning Portal.

6.	POLICIES, PROTOCOLS AND GUIDELINES
The Policies below have been updated this Year. They are reviewed annually or earlier when appropriate due to changes in regulations and evidence based guidance.
•	Infection Control Policy
•	Infection Control – Biological Substances
•	Infection Control – Inspection Checklist
•	Hand Hygiene Policy
•	Cleaning Plan Protocol
•	Safe Use and Disposal of Sharps
•	Isolation of Patients Protocol
•	Specimen Handling
•	Aseptic Technique
•	Clinical and General Waste Management
•	Contagious Illness Policy
•	COSHH Policy
•	Disposable (Single Use) Instrument Policy
•	Needle Stick Injury Policy
•	Hepatitis B policy
•	Laundering of Linen Policy
•	Prescribing Policy
•	Staff Identification and uniform Policy
•	Staff Screening and Immunisation Policy
•	Washroom and Toilet Facilities Protocol
•	Legionella Management Policy