Infection Control Statement (2023)

St Mary’s Surgery Ely

INFECTION CONTROL ANNUAL STATEMENT 2023

 Purpose:

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.

Training:

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%

 Policies:

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.

 

 

Staff training

Staff training is important to us. We regularly review our staff to ensure they have the right qualifications, skills, knowledge and experience to do their jobs.

We also cover mandatory training for all staff including basic life support, infection control, fire safety, and safeguarding. For our clinical staff, we offer specific training appropriate to their role, including immunisation, cervical smear and long-term conditions updates.

Every couple of months, the surgery closes for whole practice training. These afternoons enable all our staff to be brought up-to-date on all they need to know – for the benefit of our patients.

You can find details of the dates, throughout the year, that we are closed for training on our home page.

When the surgery is closed, please call 111 if you have a medical concern. Call 999 in a true emergency situation.

Updated: 20.9.22

Change of personal details

It is important that personal details on medical records are kept up-to-date. If you have changed your name, address, phone number or marital status, please do let the surgery know as soon as possible, so your records can be accurately maintained.

If your name has changed due to marriage or by Deed Poll, please provide a copy of the relevant documentation to be added to your records.

If you have changed address, please check if you are still within our practice area boundary.

You can also update your next of kin, carer details or responsibilities, and other changes, such as Power of Attorney details, too. We will happily record these changes to your medical record.

If you have online access to your record – via SystmOnline or the NHS App – you can update your personal details yourself, otherwise please contact the surgery.

If you move away from our practice boundary area, you have 30 days to register with a new GP practice before we deduct your medical records.

Updated: 18.11.21

Carers

It is important that we know if you are a carer so that we can make sure you receive information, services and the help that is available. Please contact our Patient Services Team to find out how the surgery can support you in your carer role.

Find out more about further help and support available to you if you are a carer.

Please note – COVID vaccines and carers: 

The current government regulations regarding carers receiving the COVID vaccination defines carers as ‘those who are eligible for carer’s allowance, or those who are the sole or primary carer of an elderly or disabled person who is at increased risk of COVID mortality and therefore clinically vulnerable’.

To ensure your records are coded as a ‘carer’ we need the following information:

  • Are you a paid carer and if so who employs you?
  • Do you receive the carer’s allowance?
  • Who do you care for?
  • Are you the sole or primary carer of an elderly or disabled person?
  • Are they registered at the surgery and have they given you permission to contact us on their behalf?
  • If you became unwell would the person you care for need outside support?

If you do not fit these criteria then we are unable to code you as a carer on our medical records system.

Updated: 3.3.21

Feedback and comments

We make every effort to give the best service possible to everyone who attends St Mary’s Surgery, and welcome comments and feedback to help improve the services we provide.

We would like to hear from you if you have a suggestion on how we can do things better and improve patients’ experiences. We would also like to hear from you if you are pleased with the care and service you have received from the surgery. We will let staff involved know and share the good practice across our teams.

Updated 25.2.21

Medicines not currently prescribed on the NHS

Here at St Mary’s Surgery your doctor, nurse or pharmacist will generally not give you a prescription for medication that is available to buy over-the-counter (OTC) from local pharmacies or supermarkets.

This covers medicines or treatments for a range of minor health conditions including cough and cold treatments, eye drops, headache tablets, laxatives, sun cream lotions, vitamins and probiotics. All these medicines are widely available from supermarkets and pharmacies at reasonable cost.

Patients are encouraged to keep a small supply of simple treatments in their own medicine cabinet so they are able to manage minor ailments at home.

By reducing the amount it spends on OTC medicines, the NHS can give priority to treatments for people with more serious conditions, such as cancer, diabetes and mental health problems.

Updated 25.2.21

Patient Dignity Policy

This policy sets out the St Mary’s Surgery provision to ensure that patients are afforded privacy and dignity, and are treated respectfully, in all appropriate circumstances where there is the potential for embarrassment or for the patient to feel ‘ill at ease’.

The requirement to respect patients is the responsibility of all staff, not just those in direct clinical contact with the patient.

View our full patient dignity policy.

National data opt-out

Your data matters to the NHS. Information about your health and care can be used to help improve not only your individual care, but can help speed up diagnoses, plan local and regional health services and research new treatments.

The NHS is committed to keeping patient information safe and always being clear about how it is used.

You can choose whether your confidential patient information is used. On 25 May 2018, the national data opt-out programme was introduced, enabling patients to opt-out from the use of their data for research or planning purposes.

Find out how you can opt-out.

Or find out more about how your information is used.

Updated 19.2.21

Violence and abuse

St Mary’s Surgery fully supports the NHS Zero Tolerance Policy. The aim of this policy is to tackle the increasing problem of violence against staff working in the NHS. We aim to treat our patients courteously at all times and expect our patients to treat our staff in a similarly respectful way.

St Mary’s Surgery staff have the right to care for others without fear of being attacked or abused and we have a zero tolerance policy to any threatening, abusive or violent behaviour against any of our staff or patients.

Patients using threatening or violent behaviour to GPs or any other person on the practice premises may be removed from the patient list with immediate effect.

Updated 15.9.22

Out of hours emergency service

When the surgery is closed and in a genuine medical emergency only, patients should telephone NHS 111.

When the practice is closed, any calls to the surgery (01353 663434) will receive a recorded message advising of the surgery opening hours and to hang up and dial 111 in a genuine medical emergency.

All 111 calls will be assessed and either:

  • Medical advice given
  • You will be referred to a healthcare professional for further advice
  • Arrangements made for you to be seen by a healthcare professional at a local centre (Princess of Wales Hospital, Ely or North Cambridgeshire Hospital, Wisbech or Doddington Hospital)
  • Arrangements made for you to be visited at home if you are bedbound by your illness or genuinely housebound
  • A 999 ambulance despatched, if appropriate.

The Cambridgeshire and Peterborough Clinical Commissioning Group is responsible for commissioning these services.

Updated 19.2.21