Infection Control Annual Statement

Surgery: Dean Cross Surgery, Plymouth.
Infection Prevention & Control (IPC) Lead for this Surgery: Alice Wilson, Lead Practice Nurse
The IPC Lead is supported by: Kevin Marsh, Project Manager
Registered Manager (CQC): Claire Woodward, Senior GP Partner
Date of last Infection Control Audit: February 2024

Purpose of this statement

This annual statement will be generated each year in May 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. It summarises:

  • 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 taken/planned.
  • Details of any risk assessments undertaken for prevention and control of infection
  • Antimicrobial Stewardship
  • Details of staff training
  • Any review and update of policies, procedures, and guidelines

Infection transmission incidents (Significant Events)

Significant events (which may involve examples of good practice as well as challenging events) are investigated in detail to see what can be learnt and to indicate changes that might lead to future improvements. All significant events are reviewed monthly at the Clinical meeting and learning is cascaded to all relevant staff.

In the past year there have been no significant events raised that related to infection prevention and control.

The Lead Practice Nurse attends the monthly Clinical Meeting and discusses Infection prevention & Control matters.

Infection Prevention Audit and Actions

The Infection Prevention and Control audits have been completed by Alice Wilson, Lead Practice Nurse. As a result of the audit, the following actions have been taken:

  • Construction of a wide ranging short/medium/long term action plan.
  • Implementation of the FR rating system across all areas of the Surgery (April completion).
  • Discussion with the cleaning team about the required standards of cleaning and remedial actions from the IPC Audit; this included notification of the FR rating system.
  • All rooms updated with the required IPC posters, IPC information board established in the staff room, and relevant posters added to the waiting rooms and toilets (April completion).
  • Trial commenced of IPC workbooks for Nursing & HCA staff.
  •  Non laminated posters removed from toilets.
  • Clinical curtains changed/dated as appropriate.
  • Window curtains removed in Room 9.
  • Pillows replaced with fully wipeable ones to comply with IP&C standards.
  • Hand gel replaced so that it is pump operated.
  • Renewal of all handwashing guidance posters to clinical rooms along with a new inoculation injury guidance poster (April completion).
  • Handwashing education session to all practice staff at the quarterly practice training afternoon.

As a result of the audit, these additional actions are planned:

  • Re-provision of cleaning store in an improved specification and location.
  • Infrastructure plan to include maintenance tasks and equipment replacement program.
  • Additional in-house education to update with clinical staff on the revised standards required[MK(CS2] .
  • Trial & review laminate covering for damaged desk tops.
  • Individual handwashing audits.

Dean Cross Surgery plan to undertake the following audits in 2024.

  • IPC Re-audit early May 2024; this will include external IPC expert professionals as verification & support for the process established in the Surgery.
  • External IPC visit June 2024.
  • Monthly cleaning audits.
  • Safe management of care equipment audit.

Risk Assessments

Risk assessments are carried out so that best practice can be established and then followed. In the last year the following risk assessments were carried out / reviewed:

Immunisation: As a practice we ensure that all of our staff are up to date with their Hepatitis B immunisations and offered any occupational health vaccinations applicable to their role (i.e. MMR, Seasonal Flu). During February & March 2024 we have offered MMR to all staff who wish to have the immunisation. We take part in the National Immunisation campaigns for patients and offer vaccinations in house and via home visits to our patient population.

Hand washing sinks: The practice has clinical hand washing sinks in every room for staff to use. Instructions for effective handwashing is next to each sink too. Some of our sinks do not meet the latest standards for sinks but we have removed plugs, covered overflows and reminded staff to turn of taps that are not ‘hands free’ with paper towels to keep patients safe.

Desk surfaces: Some desks (fixed in position) have a surface that is degraded and means it can no longer be wiped clean effectively. We have trialed a vinyl covering as short-term measure and once reviewed externally will look to either apply this solution to all or look for alternative solutions.


Clinical staff and non-clinical staff undertake infection control training via Practice Index; this is completed during induction and then as part of annual update training.

P.Kennedy & A.Thomas (Physio’s) have specialist training in Joint injections and S.Baker (Lead ANP) has undertaken specialist training in Minor surgery.


All Infection Prevention and Control related policies have been updated during March and published in April.

Antimicrobial Stewardship

The Practice have completed an audit of anti-microbial stewardship and is displayed on the staff information board. This will also be reported to a Practice Clinical Meeting.

Policies relating to Infection Prevention and Control are available to all staff and are reviewed and updated annually and all are amended on an on-going basis as current advice, guidance, and legislation changes.

Review date

March 2025

Responsibility for Review

The Infection Prevention and Control Lead and the Practice Manager are responsible for reviewing and producing the Annual Statement.