Infection Control

St Thomas Medical Group  

Infection Prevention and Control (IPC) Annual Statement 2018

Person(s) responsible for reviewing this Policy Dr Lorna Coleman, Partner and Heather Baker, Practice Nurse
Date of Last Review January 2018
Date of Next Review January 2019
Reference: 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 (Practice 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 (1/1/17 – 1/1/18) there have been no Significant events raised that related to infection control, although we received one Infection Control feedback form from a patient in August 2017. The feedback raised a concern that there were no coat/bag hooks on the back of the doors in the patients’ toilets. We were grateful for that feedback although the patient declined to leave any contact details so we were unable to feedback our actions. We have now had coat/bag hooks fitted in the toilets.


Annual audits have recently been undertaken by the IPC lead (Dr Lorna Coleman) and IPC Link Practitioner (Heather Baker RGN) using the Care Setting Process Improvement tool. These audits were carried out in St Thomas, Exwick, Pathfinder and the Student Health Centres (the surgeries that are covered by The St Thomas Medical Group).

All areas of the Health Centres were audited and action plans for improvements have been produced. The completed audit sheets are stored in the IPC file in St Thomas Health Centre and the audits will be repeated in November 2018.

This process led to a substantial amount of work being carried out across all the sites to bring them in line with current CQC standards. As a Medical Group we are very pleased with the improvements, but also recognise that this is a prioritised rolling programme of work which will continue over the next few years.

Every year practice policies and procedures are reviewed by the practice IPC team to ensure compliance with best practice. The current policies have all been checked and are in date.

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.

  • Childrens Toys; Toys can be a useful distraction for children waiting in the waiting room and also in consulting rooms as an aid to relax young patients or distract them when a parent is having a consultation. Unfortunately these toys can also be a source of infection and this can be difficult to control. It was decided that the individual GPs would keep only 1 wipe-able toy in their room which would be used if necessary. The GP is responsible for the cleaning of this toy after each use and its safe storage. In the waiting area, a fixed bead table toy is provided and cleaned after each surgery session by a receptionist. Clinell wipes are used for the cleaning as per guidelines. Due to the risk of toys harbouring germs, we would advise parents to bring in their childs own toy to play with as necessary.
  • Curtains and Blinds; All the clinical rooms have wipe-able disposable modesty curtains which are replaced annually. The treatment rooms all have wipe-able window blinds which are cleaned every 6 months.
  • Flooring; Across all the health centres we are aware that, at present, we are not fully compliant with NHS recommendations with regard to flooring. Any spillages of blood or body fluids are to be avoided on a floor that cannot be cleaned effectively. Many of the treatment and GP consulting rooms have the correct flooring, but the audits did highlight that many of the floors are still needing replacement flooring. We currently have a prioritised rolling refurbishment plan in action and many of the rooms/floors have been refurbished as per current CQC standards. Doctors have been asked not to undertake clinical procedures in rooms with carpeted floors so as to minimize risk of spillage. A carpet cleaner and steamer have been purchased for use should a spillage occur in a carpeted area.
  • Cleaning Specifications, Frequencies and Cleanliness of Equipment; The practice has an environmental cleaning policy for staff to follow. The policy specifies how to clean all areas, fixtures and fittings and what products to use. Cleaning schedules and audits are reviewed and updated on an annual basis. Nursing staff clean treatment areas and equipment between patients. Personal Protective Equipment policies are in place. All the cleaning for our surgeries is now carried out by an external cleaning company (Green Machine Cleaning Company) who claim to work to CQC standards. 

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 clinical staff receive annual IPC training as part of their Continuous Practice Development. All new clinical and non-clinical staff receive IPC training and clinical staff carry out a Hand Hygiene Practical Assessment as part of their induction.


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 2018