Infection Prevention & Control (IPC) Annual Statement for Guildowns Group Practice 2025

At Guildowns Group Practice we are committed to maintain the highest standards of infection prevention and control (IPC), to ensure the safety and wellbeing of our patients, staff and visitors. Our approach includes effective, regular environmental cleaning, safe sharps disposal, effective waste management and the consistent use of personal protective equipment (PPE). All staff receive training and updates on infection control protocols, including hand hygiene and best practices for preventing the spread of infections. We continuously review and improve procedures in line with national guidance and regulatory requirements

Background

Part 3, section 1.4 of the Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance states that the Infection Control Prevention Lead should produce:

• An annual statement with regard to compliance with practice on infection prevention and cleanliness and make it available on request
• An audit programme to ensure that appropriate policies have been developed and implemented
• Evidence that the annual statement from the Infection Prevention Lead has been reviewed and, where indicated, acted upon.

Introduction

Nurse Anne Bernicchi is responsible for the management of IPC within the Practice. Since that time, she has completed additional training to gain competency to prepare for annual completion of audits, reviews of national/local guidance and updating of practice IPC practices, protocols and policies.

Policy Changes

Policies updated appropriately with current guidelines, as well as new guidance for staff on how to action various results from ECGs, dopplers and blood pressure diaries.

There is are new protocols to comply with latest guidance advising use of 70% alcohol swabs to clean surrounding skin during IMI administration of Injections to prevent introduction of disease, as well as for the administration of Inclisiran subcutaneous injections. These are stored on a shared drive accessible to all staff

Meetings & updates

Our IPC lead nurse attends the IPC Primary Care Forum meetings run quarterly by the ICB lead, as well as the Guildford and Waverley Nurse Forum quarterly meetings to discuss recent changes to guidance and updates and CQC requirements.

In house, compliance meetings within the practice held every quarter, and include IPC as a standing item, including audits, actions, plans, risk assessments and the annual IPC statement. The minutes are stored on a a shared drive.

Any significant events from errors made regarding infection control, waste management, sharps disposal, or other IPC related issues. will also be discussed at the quarterly complaints and significant events meetings. Minutes are distributed for those that are unable to attend, as well as a summary of all actions and learning points which is published for all staff.

Compliance criterion

Criterion 1

Systems to manage and monitor the prevention and control of infection - These systems use risk assessments and consider the susceptibility of service users and any risks that their environment and other users may pose to them. These are:

• Annual IPC audits, action plans, risk assessments, cleaning logs, policies and protocols
• Prevention of spread of infectious disease.

Vaccination programmes:

• Flu and Covid - A robust system was put into practice to vaccinate all our eligible patients for flu and Covid this past year. We ran weekend clinics, week clinics, a children’s flu clinic, housebound and care home visits, in order to protect as many patients as were willing.
• RSV/ Pneumococcal and Shingles - The rollout of the RSV vaccination programme in place and eligible patients invited in. We continue to make specific RSV clinics in order to accommodate this.
• We continue to run Pneumococcal and Shingles vaccination appointments for all those that fall into the eligible criteria.
• Childhood immunisations: Our childhood vaccination programme continues to run and we are aware of the new changes coming into effect in July 2025.
• Travel vaccinations: We have a travel vaccination programme, aided by a care co-ordinator, to accommodate the essential travel vaccines as provided for by the NHS. Nurses give the relevant vaccinations required and signpost patients to a travel website for further information.
• Flu Outbreaks - In the last year, we have had 3 flu outbreaks within the Nursing Homes that we care for. There is a Influenza community outbreak protocol to manage this.

 Other compliance:

•  Carpets in waiting room Risk Assessment. In the previous year we had risk assessed the carpets in the common areas of Wodeland Avenue Surgery. It was deemed due to the amount of patients as well as the cohort of patients, including unwell patients being seen by the Urgent Care Team; babies and young children; patients with chronic illness; and the elderly, that to prevent the spread of infection the flooring needed to be replaced. This is complete with a recommended hygienic flooring appropriate for GP Practices. Cleaning processes changed / discussed with cleaning company.
• Prevention of Legionnaires Disease. Managed by our Health and Safety Lead DV, there is a policy in place (this can be found on the Y drive/policies and protocols/health and safety/Legionella) as well as evidence of constant monitoring.(Y Drive/Health and Safety Monitoring keep/Legionella.)
• Suspected Infectious Patients: Patients asked to wait in their cars, or if on foot, in an isolated area so infection can be contained. Staff wear appropriate PPE and with the correct use of handwashing, cleaning of rooms, and waste management, to limit the spread of infection. Policy in place: Y Drive/Policies and Protocols/Infection Control/Dealing with possible infectious patients.
• Training: Guildowns Group Practice, being a large practice, as well as a training practice, means that many new staff members/trainees come and go throughout the year. Essential IPC online training and reading of GGP policies and protocols in order to become familiar with procedure to prevent the spread of infection and disease. Random handwashing audits by our H&S lead and compliant waste management all contributes to the prevention of infection.
• Waste / sharps management. This is included in our Waste management policy found on the Y drive under Policies and Protocols. This includes management of sharps disposal. We have ongoing reminders to ensure the correct waste /sharps are disposed into the correct bags/sharps bins.

Criterion 2

The provision and maintenance of a clean and appropriate environment in managed premises that facilitates the prevention and control of infections.

• Cleaning company: Up to date on required protocols for the appropriate cleaning of all four surgeries.
• Handwashing policy and audits. Online training at induction
• Waste Management - Protocol in palce and regular training of staff.
• Cleaning Logs. Equipment is cleaned after use / each day and the relevant QR code scanned and signed. QR codes are on the walls in all Minor Procedure rooms and are scanned/signed after use on the day. QR codes are available on the ear irrigation equipment box, Spirometry box and in use for Daily Cleaning of clinical rooms. These logs are kept on Teamnet.
• Aseptic Technique. According to the latest guidelines. Training of all staff involved in procedures requiring aseptic technique. Single use equipment is in use where appropriate.
• PPE. Appropriate use of masks, gloves, aprons through training. Correct use of spills kit.
• Designated Cleaning time: These are to allow time for staff to clean equipment and rooms as well as empty waste.

Criterion 3

Appropriate antimicrobial use and stewardship to optimise outcomes and to reduce the risk of adverse events and antimicrobial resistance. 

• Handwashing and use of hand sanitizer - use of soap for handwashing, antimicrobial hand sanitizer if the dirt is not visible.
• Dressings - appropriate use of antimicrobial dressings achieved by staff training. Wound dressing formulary and advice has changed to reduce anti-microbial resistance. Quarterly wound management meetings are now taking place to address this as well as other relevant topics such as chronic leg ulcers, compression, abscesses, pilonidal sinus dressings to name but a few. Nurses and heathcare assistants are all up to date on training, or are booked onto training in order to remain up to date on wound and leg ulcer management. We have a designated tissue viability nurse  who is in charge of monitoring and supporting GP practices and local tissue viability nurses are also available for nurses to be in contact for advice if required.
• Cleaning of equipment - appropriate wipes and solutions used to clean equipment and furniture. QR codes replace cleaning logs as evidence. These are documented on Teamnet.
• Prescribing - our pharmacists have run audits and discussions have taken place reviewing these at our clinical meetings. GGP make every effort to follow guidance as appropriate.
• Storage of cleaning products according to COSHH.

Criterion 4

The provision of suitable, accurate information on infections to service users, their visitors and any person concerned with providing further social care support or nursing/medical care in a timely fashion.

• Notification of infectious diseases - patients will be called if they have been in direct contact with any infectious disease as notified to us by UKHSA.
• Notifications to patients - notifications will be sent to patients via AccuRx (text), emails, calls or letters to inform them about flu season and encouraging them to attend flu clinic. Invitations for appropriate vaccinations such as RSV, Shingles, Pneumonia and MMR.
• Posters and leaflets in waiting room - updated regularly.
• Staff training through staff meetings, practice based quarterly learning sessions, online training as well as a weekly newsletter with appropriate links and information.

Criterion 5

The practice has a policy for ensuring that people who have or are at risk of developing an infection are identified promptly and receive the appropriate treatment and care to reduce the risk of transmission of infection to other people.

• Notifications to patients - AccuRx systems allows us to send bulk notifications to patients efficiently.
• Vulnerable and immunosuppressed patients - patients who fall into this category are offered vaccines and other regular investigations to ensure patient safety and prevention of illness. This may include families of these patients.
• Appropriate treatment or onward referral - keeping abreast of current treatment updates through training and good communication.
• Prevention of spread - adherence to protocols to maintain and prevent spread of infection such as isolating suspected infectious patients when attending surgery, advising patients to isolate from the local community and family members and encouraging infection control measures such as hand washing, mask wearing, cleaning of environment.
• Checking appointment/clinical system to ensure patients who may have been in contact are notified and given correct information on what to expect/be aware of and what to do.

Criterion 6

Systems are in place to ensure that all care workers (including contractors and volunteers) are aware of and discharge their responsibilities in the process of preventing and controlling infection.

• IPC policies and protocols - Kept on the shared drive and staff intranet for easy access for staff.
• Annual IPC audits - Undertaken annually at each site and kept on the shared drive
• Aseptic technique – staff training and protocol available
• Hand washing and PPE - Regular training and physical checks as appropriate.
• Cleaning protocols - Kept on the shared drive

 Criterion 7

The provision or ability to secure adequate isolation facilities.

• Designated clinic room - most cases seen that are suspected to be highly infectious are examined at our Wodeland Avenue surgery by our urgent care team. A designated examining room is allocated for this purpose. If for some reason the room is not available, the patient is asked to wait in the car until called through by the clinician. The patient does not wait in the waiting room.
• The clinician will wear the appropriate PPE and deposit this correctly into the waste once the patient has left and the room cleaned thoroughly.
• The patient will be asked to leave via the back door to prevent contact with other patients or reception staff.
• Cleaning protocols are in place for once the patient has departed the room.
• Any notifiable diseases will be recorded and the relevant notifications sent through to UKHSA.

Criterion 8

The ability to secure adequate access to laboratory support as appropriate.

• Collections of samples - prearranged times for each surgery three times per day for the collection of samples, extra collection times are arranged for late evening or Saturday (enhanced access) clinics.
• Abnormal samples are called through to the surgery by the laboratory, a telephone number is available to contact the lab for any queries about samples.   
• Notifications via email are also sent from the laboratory to update us on waiting times or any other changes.

Criterion 9

The practice has and adheres to policies designed for the individual’s care, and provider organisations that will help to prevent and control infections.

Policies and protocols are stored on a shared drive, these are reviewed and updated regularly to ensure high standards of infection control, as well as health and safety measures in order to protect both patients and staff alike. These include third party/contractors sued by the practice for waste management, cleaning company  and also include updates from council, ICB, national safety alerts for equipment and drugs and calibration of equipment.

Criterion 10

The practice has a system or process in place to manage staff health and wellbeing, and organisational obligation to manage infection, prevention and control.

• Wellbeing support staff members - Staff members can access support via our Employee Assitance Programme, we also have mental health first aiders on staff at each branch.
• Policies to manage staff illness to reduce spread of infection - staff who contract vomiting and diarrhoea need to be free of symptoms for 48 hours before returning to work. Current guidance for staff who are unwell is that covid testing is not required, however, if a test has been taken and shows positive for covid, the advice is to remain at home for 5 days to ensure spread does not take place amongst other staff members as well as patients.
• Vaccinations - immunisation history is screen for all staff to ensure up to date in line with their roles, an referred to occupational health as appropriate. Staff are also encouraged to have the flu vaccine annually.
• Handwashing - all staff members do online training to learn the correct technique for handwashing. Training audits are checked by management and the Health and Safety officer conducts periodic physical checks.
• Provision of equipment - PPE, soap, hand sanitizer and antibacterial wipes are freely available for staff use and visiting patients
• All staff complete annual IPC training
• Our IPC lead nurse maintains and ensures all protocols are in place, conducts annual IPC audits and compiles action plans accordingly, working with all staff to ensure high standards are maintained in order to prevent spread of infection eg. all clinicians must be bare below the elbows, no jewellery, aseptic technique to be followed.