IPC Annual Statement Report January 2024

The Heron Medical Practice


This annual statement will be generated each year in November 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 will be published on the practice website and will include the following summary:

  • 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 the prevention and control of infection
  • Details of staff training
  • Any review and update of policies, procedures, and guidelines 

Infection Prevention and Control (IPC) lead

The lead for infection prevention and control at The Heron Medical Practice is Rachel Bain Senior Nurse

The IPC lead is supported by Abigail Powell Practice Nurse and Santhosh Sebastian GP.

a.         Infection transmission incidents (significant events)

Significant events involve examples of good practice as well as challenging events.

Positive events are discussed at meetings to allow all staff to be appraised of areas of best practice.

Negative events are managed by the staff member who either identified or was advised of any potential shortcoming. This person will complete a Significant Event Analysis (SEA) form that commences an investigation process to establish what can be learnt and to indicate changes that might lead to future improvements.

All significant events are reviewed and discussed at several meetings each month. Any learning points are cascaded to all relevant staff where an action plan, including audits or policy review, may follow.

In the past year there have been no significant events raised that related to infection control. There have also been no complaints made regarding cleanliness or infection control. 

b.         Infection prevention audit and actions

External Infection Control Audits will be carried out by an Infection Prevention Solutions Auditor in February 2024

Internal Audits carried out this year

Internal IPC audits of all 3 sites April 2023.

Hand Hygiene Audit – Clinical and Non- Clinical Staff. April 2023

Waste Audit Hersden -May 2023,

Waste Audit Beltinge and Reculver September 2023

Waste Audit St Anne’s January 2024

Sharps Audit – as part of Waste Audits

In 2024

  • Hand hygiene audit will be done on a rolling programme assessing around 10 staff per month, ensuring all staff are assessed within the year and allowing for any new staff who join the practice to be assessed immediately.
  • National Standards of Cleanliness to implemented.
  • Aseptic Technique Procedure Audit.
  • PPE (putting on an removing PPE) on a rolling programme as per hand hygiene audit.
  • Safe Management of care equipment Audit Monthly
  • Safe Management of the Care environment Audit Monthly
  • Aseptic Technique procedure competence – one per month to encompass all clinical staff.

c.         Risk assessments 

Risk assessments are carried out so that any risk is minimised to be as low as reasonably practicable. Additionally, a risk assessment that can identify best practice can be established and then followed.

In the last year, the following risk assessments were carried out/reviewed:

Risk Assessments carried out following IPC internal audits – Carpeted consultations rooms – to be replaced on release of funding.

Non- wipe-able chairs in consultation rooms to be replaced as funding released.  

Non lidded general waste bins were replaced in all clinical rooms with pedal operated lidded bins.

COSHH risk assessments are updated on a yearly basis and as any new substances come into the practice. 

Privacy curtains are changed on a 6 monthly basis in January and July.

Assessment of Staff training on induction and annual updates.

These will all be reviewed in 2024

d.         Training

In addition to staff being involved in risk assessments and significant events, at The Heron Medical Practice all staff and contractors receive IPC induction training and handwashing training on commencing their post. Thereafter, all staff receive refresher training annually.

e.         Policies and procedures

Policies relating to infection prevention and control are available to all staff and are reviewed and updated annually. Additionally, all policies are amended on an ongoing basis as per current advice, guidance, and legislation changes. 

f.          Responsibility

It is the responsibility of all staff members at The Heron Medical Practice to be familiar with this statement and their roles and responsibilities under it. 

g.         Review

The IPC lead Rachel Bain is responsible for reviewing and producing the annual statement.

This annual statement will be updated on or before January 2025

Signed by

Rachel Bain

For and on behalf of The Heron Medical Practice