Staunton and Corse Surgery, Gloucester Road, GL19 3RB
Purpose
The 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. The report will be published on the practice website and will include the following summary:
- Any infections 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
- Details of any risk assessments undertaken for the prevention and control of infection
- Details of any staff training
- Any review and update policies, procedures and guidelines
Infection Prevention and control (IPC) leads
The lead for infection prevention and control at Staunton and Corse Surgery is Karina Blackwell (Clinical Manager)
The IPC lead is supported by Louise Tweney (Practice Manager)
They have both attended and IPC lead training course and attend regular updates on infection prevention in practice.
Infection transmission incidents (significant events)
Significant events involve examples of good practice as well as challenging events.
Positive events are discussed at meetings to allow all staff to be appraised in areas of good practice.
Negative events are managed by the staff member who either identified or was advised of any potential shortcoming. The person will complete a significant event analysis (SEA) form that commences and investigation process to establish what can be learnt and to indicate changes that might lead to furture improvements.
All significant events are reviewed and discussed at several meetings each month. Any learning points are cascaded to all relevant staff where an action plan, including audits or policy review, may follow.
In the past year there have been no significant events raised that related to infection control. There have also been no complaints made regarding cleanliness or infection control.
Infection Prevention Audit and Actions
The Annual Infection Prevention and Control audit was completed by Karina Blackwell and Louise Tweney in September 2025
As a result of the audit, the following things have been changed in Staunton and Corse Surgery
- Wall hung hand soap and alcohol dispensers have been placed in all areas
- Hand mosituriser wall dispenser has been installed in the kitchen.
- Room 5 – minor ops clinical room has been tidied to keep surfaces clutter free, drawers purchased for clinicans paper work/books to be tidied away.
- Legionnaires testing has been completed and passed.
- Temperature of water has been improved and now suitable temperature for handwashing.
- IPC recommended reusable wipeable Tourniquets have been purchased.
- National cleaning standards have been reviewed with the cleaning company and small changes made in line with guidance
- Cleaning schedules have been placed on doors to all rooms.
- IPC policies have been re-written as standard operating procedures and are available to all practice staff on TeamNet.
In addition to the annual IPC audit and minor ops and sexual health audit is completed annually to review any post procedure infections. A total of 122 minor ops were carried out over the last year by Dr Chambers, Dr Fisher and MSK physio Melanie Eaton. These were a variety of joint injections and skin lesion/tag removals. Out of these procedures the audit found there to be no post procedure infections.
The sexual health audit showed a total of 48 procedures ranging from implant removals, implant fits, IUD/IUS removals and fits. There was one post procedure infection, skin infection following an implant fit that required a course of antibiotics and fully resolved following treatment. Following this audit a risk assessment was completed and a review of the minor ops room cleanliness, along with a refresher on aseptic technique was completed.
Staunton and Corse Surgery plan to undertake the following audits in 2026
- Annual Infection Prevention and Control audit
- Hand hygiene audit
- New Cleaning Standards – 3 Monthly Room Audits
- 3 Monthly Waste audit
- 3 Monthly Sharps bin audit
- Weekly Cleaning Spot Checks
- Monthly building maintenance checks
- Regular water temperature testing checks
- Cold chain audit
- Fridge temperature audit
- Sexual health and minor ops audit
Risk Assessments
Risk assessments are carried out Annually.
Legionella (Water) Risk Assessment: The practice has conducted/reviewed its water safety risk assessment to ensure that the water supply does not pose a risk to patients, visitors, or staff.
Immunisation: As a practice we ensure that all 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 and Covid vaccinations). We take part in the National Immunisation campaigns for patients and offer vaccinations in house and via home visits to our patient population.
Curtains: The NHS Cleaning Specifications state the curtains should be cleaned or if using disposable curtains, replaced every 12 months or more frequently if visibly soiled. To this effect we use disposable curtains and ensure they are changed every 12 months and 6 montlhy changes for the minor op room. The window blinds are very low risk and therefore do not require a particular cleaning regime other than regular vacuuming to prevent build-up of dust. All curtains are regularly reviewed as part of the weekly room checks and changed if visibly soiled.
Cleaning specifications, frequencies, and cleanliness: We also have a cleaning specification and frequency policy which our cleaners and staff work to. An assessment of cleanliness is conducted by the cleaning team and logged. This includes all aspects in the surgery including cleanliness of equipment.
Hand washing sinks: The practice has clinical hand washing sinks in every room for staff to use. Hand washing sinks: The practice has clinical hand washing sinks in every room for staff to use. Some of our sinks do not meet the latest standards for sinks but we have removed plugs, covered overflows. We have also replaced our liquid soap with wall mounted soap dispensers to ensure cleanliness.
Training
- All our staff receive annual training in infection prevention and control.
- All clinical and non -clinical staff have completed e-learning training.
- IPC lead should attend quarterly IPC Lead Practice Nurse forums organised by IPC NHS- SW England
RAG rating IPC audit tool
The annual IPC audit was carried out using the RAG rating audit tool. The overall score on the initial inspection was 92.86%. This was below the recommended national average of 95%. An action plan was conducted to tackle the areas that required improving with a timescale of 3 months to action the changes.
Following changes from the action plan re-audit took place and the rating is now 97.96% and therefore now above the 95% acceptable standard of IPC.
A risk assessment for the use of carpeted areas in clinical rooms, replacement of blinds in remaining clinical rooms, longer term considerations include complete removal of carpets remaining in clinical rooms and communal areas and surface redecoration. Some the areas of concern will be carried out with the proposed building work/expansion we hope to happen in the future.