Infection Control

St Thomas Medical Group

002 – Infection Control Annual Statement 2020

Person(s) responsible for reviewing this Policy Dr Lorna Coleman, Partner and Heather Baker, Practice Nurse
Date of Last Review January 2020
Date of Next Review January 2021
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 (1/1/19 – 1/1/20) there have been no Significant events raised that related to infection control.


Annual audits are undertaken by the IPC lead (Dr Lorna Coleman) and IPC Link Practitioner (Heather Baker RGN) using the Care Setting Process Improvement tool. These audits are 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 are audited and action plans for improvements are produced. The completed audit sheets are stored in the IPC file in St Thomas Health Centre. We will continue to carry out these audits on an annual basis.

A rolling programme of refurbishment will continue. Treatment rooms are being repainted and we are currently trying to obtain funding to have all the flooring in Exwick health centres’ consulting rooms changed to wipeable.

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.

Due to an increasing incidence of latex allergy, all the non-sterile examination gloves used in the surgery are latex free. The sterile gloves used for minor operations contain latex but we check for any history of latex allergy with the patient prior to the procedure and have access to latex free if required.

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 (Workplace Solutions) who 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 new 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 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.


Everyone is aware of the presence of this respiratory virus that has originated from China. St Thomas Medical Group is strictly following the guidelines issued by Public Health England. These are checked daily due to the constant changes in advice.

The main guidelines we are following are:-

  1. Advising anyone with possible symptoms to ring 111 initially for advice
  2. Strict triage system – we have a team of clinicians who are available every day to offer telephone advice to anyone with worrying symptoms.
  3. All clinical and non-clinical staff have received, and will continue to receive, up to date training and guidance to try and ensure patients and staff risks are to a minimum.
  4. Full supplies of personal protective equipment are available at all our sites (masks, goggles).
  5. Each site has a designated isolation room for use in the event of a patient attending with concerning symptoms.

Policies, Procedures and Guidelines

Policies and procedures, relating to Infection Prevention and Control (IPC), will be reviewed as current advice changes and updated annually to ensure compliance with best practice. The current policies have all been checked and are in date.

Dr Lorna Coleman/Heather Baker     February 2020