Infection Control Statement (2022)


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 24/08/2022

Known learning events related to IPC during 2022

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 no 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 in March 2022, coinciding with a voluntary site visit from Helen Wickenden, lead nurse for IPC for Cambridge & Peterborough ICS. There were no concerns or recommendations made as a result of this visit.

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

Annual Infection Prevention and Control audit Quarterly handwashing audits

Quarterly Cytology audits

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 and monthly checks are conducted in both the temporary surgery location at the POW site and also the administrative houses on St Mary’s Street to ensure that the water supply does not pose a risk to patients, visitors, or staff.

Immunisation: – St Mary’s Surgery ensures that our 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.

Covid19: – All staff in patient facing roles wear facemasks to offer protection to our patients. Patients are encouraged but not mandated to wear facemasks, per the Government guidance issued in April 2022. PPE is procured weekly from central government supply and is readily available for all staff to use. These provisions include gloves, aprons, 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 78%


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 2023

Next review date:

January 2024 (for the 2023 year)

Responsibility for review:

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

Download a copy of this Policy