Infection Control

St Thomas Medical Group

002 – Infection Control Annual Statement 2023

Person(s) responsible for reviewing this Policy Dr Lorna Coleman, Partner and Heather Baker, Practice Nurse
Date of Last Review January 2023
Date of Next Review January 2024

The Health and Social Care Act 2008 – Code of Practice on the prevention and control of infections & related guidance


This annual statement will be generated each year. It will summarise:

· Any infection transmission incidents and action taken (these will be reported in accordance with our Significant Event procedure)

· The annual infection control audit and actions undertaken

· Control risk assessments undertaken

· Details of staff training

· Details of infection control advice to patients

· Any review and update of policies, procedures and guidelines


St Thomas Medical Group Lead for Infection Prevention and Control is Dr Lorna Coleman, she is supported by Mrs Heather Baker RGN (Lead IPC Nurse) and Mr Chris Stoppard (Practice Manager).

St Thomas Medical Group ensures compliance with “The Code of Practice for the Prevention and Control of Infection and Related Guidance (Hygiene Code) DOH 2010.

This team will keep updated on infection control and share necessary information with staff and patients throughout the year.

Significant Events

The practice has regular quarterly meetings whereby any significant or critical events are discussed.

In the past year (1/1/2022 – 1/1/2023) there have been no Significant events raised that related to infection control.


Annual audits are completed by the IPC lead (Dr Lorna Coleman) and IPC Lead Nurse (Heather Baker RGN) using the Care Setting Process Improvement tool.

All areas of St Thomas, Exwick and the Student Health Centres are audited and action plans for improvements are produced. The completed audit sheets are stored in the IPC file.

Every year practice policies and procedures are reviewed by the practice IPC team to ensure compliance with best practice.

We aim to share information with our patients and a copy of this Annual Statement will be published on our practice website. We will notify patients of any seasonal outbreaks via a notice board in the waiting room and on our website.

Risk Assessments

Regular risk assessments are undertaken to minimise the risk of infection and to ensure the safety of patients and staff. The following risk assessments relating to infection control have been completed in the past year and appropriate actions have been taken.

Covid-19 Measures –

During the last couple of years of Covid outbreaks, we have used isolation rooms extensively. Following national government guidance, we have stopped using these and are back up to full face to face contact. Very recently the medical group made the decision to stop mask wearing within the surgeries unless – staff member has a cold, sore

throat etc, contact with a close family member who has tested positive to Covid, personal preference or clinician is knowingly seeing a patient with respiratory symptoms. Patients are no longer required to wear a mask, but we politely request that, if you are able, you wear a mask if seeing a clinician regarding a respiratory infection. NHS staff can access Lateral Flow testing kits and we are testing ourselves if any concerns regarding personal illness or confirmed Covid contact.

Infection Control –

Since the start of the Covid pandemic we have supplied hand gel throughout the surgeries for patient use. This is still available for use, and we strongly recommend that patients use this on entering and leaving the surgeries. If you find a container that is empty, please inform reception and we will replace it immediately. Thank you.

Staff Training

All staff are aware of the practice hand hygiene policy and instructions for hand cleansing are displayed in all clinical rooms and health centre toilets. Members of the clinical team carry out a Hand Hygiene Assessment annually. All nurses receive annual IPC training as part of their Continuous Practice Development. All new clinical and non-clinical staff receive IPC training as part of their induction. All staff abide by the recommended government guidance for infection control within a healthcare setting.


We attempt to inform our patients about any infection issues, i.e., flu season, on notice boards at the surgery and on our practice website.

Patients who are thought to have an infection that may be contagious e.g., chickenpox are asked to wait in a designated isolation room rather than the main waiting room. With our telephone triage system now in place we hope to reduce the number of infectious patients having to come to the surgery by trying to help/advise them over the phone.

All patients requiring dressings who are known to have MRSA infection are treated at the end of the nurses list so that the room can be prepared and cleaned after the consultation. All patients with MRSA have an individual risk assessment completed which is shared with them to ensure everything possible is done to reduce the risk of cross infection. There have been no reported cases of MRSA acquired in the practice.

Policies, Procedures and Guidelines

Policies relating to Infection Prevention and Control will be reviewed as current advice changes and updated annually if appropriate.

Dr Lorna Coleman/Heather Baker January 2023