Infection Control

St Thomas Medical Group  

Infection Prevention and Control (IPC) Annual Statement 2017-2018


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 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 (1/1/16 – 1/1/17) there have been no Significant Events raised that related to infection control.


An extensive audit was undertaken by the IPC lead (Dr Lorna Coleman) and IPC Link Practitioner (Heather Baker RGN) using the Care Setting Process Improvement tool.

All areas of the St Thomas Health Centre will be audited and an action plan for improvements will be produced. The completed audit sheets will be stored in the IPC file and the audit will be repeated in March 2018.

During 2016 the IPC Link Nurses at Exwick and the Student Health Centres carried out their annual IPC audits. This resulted in a few updates at the Student Health Centre but a substantial amount of work was carried out at Exwick to bring it in line with current CQC standards. As a Medical Group we are very pleased with the improvements.

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.

  • Children’s 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. NHS cleaning specifications recommends weekly cleaning of toys. It was decided that only a small number of wipeable plastic toys should be kept in consulting rooms, these will be kept in a small plastic toy box. In the waiting area fixed bead table toys would only be provided. Waiting room toys are cleaned daily (after each surgery by reception staff) and consulting room toys will be cleaned weekly by the relevant clinician using Clinell wipes. We are currently trialling the removal of all toys from the consulting rooms due to time difficulties involved in the cleaning of these toys. The risk of toys harbouring germs is quite high so we would advise parents to bring in their childs own toy to play with as necessary. 
  • Curtains and Blinds: All the clinical rooms now have wipeable disposable modesty curtains which are replaced annually. The treatment rooms all have wipeable window blinds which are cleaned every 6 months.


  • Flooring: Whilst we are a modern health centre 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. All treatment rooms have the correct flooring. Doctors consulting rooms have carpeted flooring, as does the main waiting area. It has been decided to replace the carpet when necessary with smooth impervious flooring. A few of the doctors consulting rooms have already been upgraded and now have wipeable, impervious flooring. 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 a designated lead for cleaning and there is 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. This year the IPC Lead & the IPC Link Nurse carried out a full Cleanliness Audit and, as a result of this, a professional cleaning company has been employed to carry out the full cleaning requirements across all the St Thomas Medical Group sites. They will start in March.

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.


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 2017

Ref: The Health and Social Care Act 2008 – code of practice on the prevention and control of infections and related guidance.