Infection Control Statement (2023)

St Mary’s Surgery Ely



This annual statement will be generated each year 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 undertaken.

Details of any risk assessments undertaken for prevention and control of infection.

Details of staff training.

Any review and update of policies, procedures, and guidelines.

Infection Prevention and Control (IPC) lead

The St Mary’s Surgery Lead for Infection Prevention and Control is Carly Loop (Clinical Nurse Manager).  The Infection Prevention Control Lead is supported by Tony Davies (Practice Manager).

Annual infection control training is a mandatory requirement for all surgery staff. Carly Loop last updated her infection control training on 24/01/2023 and will attend off site PCN wide training on 12.01.2024

Known learning events related to IPC during 2023

Learning 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 learning events are reviewed annually during staff clinical governance training.   Significant events (where actual harm is identified to have been caused) are investigated in the same manner.

In the past year there has been 0 learning or significant events raised that related to infection control at St Mary’s Surgery.

Infection Prevention Audit and Actions

The Annual Infection Prevention and Control audit was completed by Carly Loop on 08/08/2023, encompassing all three floors of the surgery at 37 St Mary’s Street utilising iCaT auditing software.  No deficiencies were found during the annual audit.

St Mary’s Surgery will undertook the following IPC related audits in 2022, and plan the same for 2023:-

  • Annual Infection Prevention and Control audit
  • Quarterly handwashing audits
  • Quarterly Cytology audits
  • Weekly cleaning inspections
  • Pre Acceptance waste Audit (through Anenta)
  • Duty of Care Waste Audit (through Anenta)

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: –

Legionella (Water) Risk Assessment: – Weekly checks are conducted in the administrative houses on St Mary’s Street by the assistant practice manager, Becky Taylor, to ensure that the water supply does not pose a risk to patients, visitors, or staff.  The main surgery premises is under the professional management of 4i Water Services Ltd.   Reports are kept with the practice manager.

Immunisation: – St Mary’s Surgery ensures that our staff clinical staff are up to date with their Hepatitis B immunisations. All surgery staff are offered annual influenza vaccination and any COVID 19 vaccinations as recommended by the UK Government.

Clinical Waste: –  Our clinical waste collections are overseen by Anenta who manage the collection of both bagged waste and sharps containers.

Covid19: – The national guidance that has required the continued wearing of face masks and face coverings across health and social care settings was withdrawn on Tuesday 16 May 2023.  Our staff are still asked to wear facemasks to offer protection to our patients if and when exhibiting any signs/symptoms of a respiratory tract infection.  Patients are encouraged but not mandated to wear facemasks in the same circumstances.  Masks and alcohol based hand gel are readily accessible in every waiting area and at both main entrances to the surgery.  PPE is procured from our private suppliers and these provisions include gloves, aprons, masks, alcohol based hand gel and, where indicated, face shields and full body gowns.

Cleaning of the premises:

The surgery is cleaned by a professional cleaning company following the end of each working day.  Clinical staff are responsible for cleaning their own working areas between patient interactions during their working day.


Annual Infection control training is a mandatory requirement for all surgery staff. Our current compliance rate for all staff to be up to date with their training is 74%


All Infection Prevention and Control related policies are in date for this year.   Policies relating to Infection Prevention and Control are available to all staff, are reviewed, and updated bi-annually, and all are amended on an on-going basis as current advice, guidance, and legislation changes.

Annual review completion date:

January 2024

Next review date:

January 2025 (for the 2024 year)

Responsibility for review:

The Infection Prevention and Control Lead is responsible for reviewing and producing St Mary’s Surgery’s Annual Statement.