Infection Control Statement 2022/23



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)
  • Details of infection control audits and any actions undertaken
  • Details of infection control risk assessments undertaken
  • Details of staff training
  • Any reviews and updates of policies, procedures and guidelines


Responsibilities within the Practices:

  • Infection Prevention and Control GP: Dr M Walker 
  • Infection Prevention and Control Nurse: Jan Paish (CMC) 
  • Infection Prevention Administrator:    Ellie Roberts

Any information received, learnt on Study Days and meetings held will be shared with the Practice at CPD meetings and all staff meetings.

Anu Kaul (PN) and Carmel Johnson (PN) will be transferring to Lead Nurse roles in 2023-24


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.

No SEAs relating to IPC.  


Learning or changes made:

  1. Build up of clinical waste at Surbiton Branch due to non-collection of waste.
    • The incident was noted by Lucy, TNA.  The waste had not been collected and as a result, it was not possible to put it in a full orange bag.
    • The waste company were contacted and it transpired that the waste consignment renewal documentation had been sent to a member of staff no longer working at the practice and the contract ended without the PM or OM knowing.
    • Forms completed and waste collection re-instated.

Learning: reminders set for waste consignment notes on GP Teamnet to ensure visibility despite any changes in staffing.  Renewals also requested to be copied to the generic practice account rather than reliance on one team member.



Minor Operations:

  • Infection rates post joint injections carried out at the surgery are audited on an annual basis.
  • Orchard – 0 post operation or joint injection infections 2022-23
  • Churchill – 0 post operation or joint injection infection 2022-23

Clinical Audit

  • Orchard & Churchill  - Broad spectrum antibiotic prescribing audit undertaken by Dr Maggie Walker (CMC) and Dr Haythem Naseef (Orchard)

Annual Audit 

  • Undertaken in September 2023.  

Actions undertaken 2022-23

Legionella monitoring outsourced to SMS Environmental to ensure compliance.

PPE guidance in practice updated in July 2022.  Staff continued to wear masks when in F2F appointments with patients, but it became patient choice as to whether to wear a mask when attending the surgery. Those with respiratory symptoms requested to wear a mask whilst in the practice.

PPE Levels updated for all clinical staff

COVID-19 testing guidance amended in line with recommendations for managing infection in a healthcare setting.  The main risk to the practice remains all staff becoming infected at the same time, leading to a staffing crisis.  Risk assessment carried out as below to ensure safe working practices for staff with respiratory illness.  


Risk Assessments

Staff induction immunisations are now undertaken by The Private Group, Groves Medical Centre.

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:

  • Management of patient with or potentially having Covid-19 infection
  • Management of staff working with covid-19 infection
  • Management of clinical staff during pregnancy and dealing with Covid-19 infection in the community

All staff with any respiratory infections must staff off work if they feel unwell. Testing for COVID is no-longer mandatory, however, any staff who do test positive must staff off for 5 days as this is the likely infectious period.  If staff feel well enough, they may work from home.


Staff Training

All staff members are required to undertake e-learning training for Infection Prevention and Control for Non-clinical and Clinical staff once a year.  Infection Control discussed as part of induction.  

GPs have undertaken specialist training in Minor surgery, infection prevention and control and joint injections.

GP’s and specially trained nurses have undertaken specialist training in Sexual health with regards to Coil insertions and Implant insertions/removals.

Lead Administrator attended NHS England IPC refresher training on 6th April 2022 to learn about updates in recent COVID-19 and IPC policy 


Policies, Procedures and Guidelines

Policies relating to infection Prevention and Control are reviewed on an annual basis and as current advice changes.

We aim to share information with our patients and a copy of this annual statement will be available on our practice website.  We will notify patients of any potential seasonal outbreaks via our patient information screen in the waiting room and on our website.