Annual Statement for Living Well Partnership 2024-2025
Statement prepared March 2025
Annual Statement for Infection Prevention and Control (Primary Care)
It is a requirement of The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance that the Infection Prevention and Control Lead produces an annual statement with regard to compliance with good practice on infection prevention and control and makes it available for anyone who wishes to see it, including patients and regulatory authorities.
As best practice, the Annual Statement should be published on the Practice website.
The Annual Statement should provide a short review of any:
- known infection transmission event and actions arising from this;
- audits undertaken and subsequent actions;
- risk assessments undertaken for prevention and control of infection;
- training received by staff; and
- review and update of policies, procedures and guidance.
Infection Control Annual Statement
Purpose
This annual statement will be generated each year in March 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 Living Well Partnership has one lead for Infection Prevention and Control:
Lucy Pritchard (Head of Nursing)
Lucy Pritchard has attended an IPC Lead training course in 2020 and keeps updated on infection prevention practice.
The IPC Lead is supported by:
Karen Hannam (Nursing Services Administrator and IPC ICB Link Nurse)
Karen has attended IPC Lead training in 2020 and keeps updated on infection prevention practice.
Infection Prevention and Control (IPC) Champions
The IPC team are supported by IPC Champions, the role of the IPC champion is to provide onsite support to the multi-disciplinary team, cascade learning and updates, champion the adherence to LWP Policies and Protocols, and carry out spot checks and audits to supplement the work of the primary IPC team. The IPC Champions by location are.
Bitterne Park: Sharon Crook
Botley: Tracy Hatch
Ladies Walk: Rachel Matcham
St Lukes: Emily Bishop
West End: Jenni Spiller
Weston Lane: Karen Cascarina
Infection transmission incidents (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. All significant events related to IPC are investigated by the IPC lead, following investigation they are reviewed at the quarterly nurse forums (for the nursing team) and/ or at the clinical staff ‘TARGET’ training events meetings where applicable, and learning is cascaded to all relevant staff.
In the past year there have been no significant events raised that related to infection control.
Infection Prevention Audits and Actions
Annual IPC Audit
The Annual Infection Prevention and Control audit was completed at each clinical site by the IPC Champions between January and March 2025. Facilities Manager Kimberley Davies was kept informed of the audit findings to address any facilities related concerns.
Following the audit the following changes in practice have been made.
- Domestic cleanliness standards will be audited internally with increased frequency and increased monitoring visits from the cleaning contract holder.
- Improvements in the decorative state and flooring of some sites have been noted, sites where improvement is required will be prioritised in order of need and scheduled as budgetary constraints allow.
The main areas for improvement from the annual audits include:
- Domestic cleaning of high and low levels needs improving, including replacing soap, alcohol gel and paper towels.
- Some chairs for staff in clinical rooms are not wipe clean, a programme of chair replacement is ongoing.
- Some patient chairs in non-clinical areas e.g., waiting room are not wipe clean, a programme of replacement is ongoing.
- Whilst some sites have undergone flooring replacement there remain areas of carpeting in a state of poor repair at some sites. This work is planned for 2025.
Annual Minor Surgery Audit
An audit on Minor Surgery was undertaken by the IPC Lead at the end of March 2025.
The partnership carried out 102 minor surgeries in the preceding 12 months, 3 post operative infections were noted. According to NICE (Context | Surgical site infections: prevention and treatment | Guidance | NICE) at least 5% of patients undergoing a surgical procedure will develop a surgical site infection, the incidence within the partnership is 2.94% and is below the national average. No infections were reported for patients who had joint injections at Living Well Partnership.
The practice has not changed minor surgery procedures in view of the results of the audit.
Hand Washing Audit
Audits on hand washing are undertaken annually across all clinical sites, the most recent hand hygiene audits were carried out in December 2024. The results of these audits were discussed at the nurse forum and will be discussed at the next in-house TARGET.
Spot Checks
Weekly spot checks are carried out across the partnership, these will focus on a clinical room or area and will check for cleanliness, sharps compliance, lack of clutter, cleaning standards etc.
Planned Audit Timetable
LWP plan to undertake the following audits in 2025:
- Annual Infection Prevention and Control audit (December 2025- February 2026)
- Quarterly Infection Prevention and Control audit (quarterly)
- Minor Surgery outcomes audit (March 2026)
- Domestic Cleaning audit monthly.
- Hand hygiene audit (November- December 2025)
- Antibiotic stewardship (date to be determined by Lead Clinical Pharmacist)
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: 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.
Immunisations: As a practice we ensure that all clinical 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, COVID). We take part in the National Immunisation campaigns for patients and offer vaccinations in house and via home visits to our patient population.
Toys: We do not have toys at any of our sites therefore a risk assessment is not required.
Hand washing sinks and non-mixer taps: The practice has clinical hand washing sinks in every room for staff to use. Risk Assessments are completed for hand basins that do not comply with current IPC standards owing to the date at which they were installed (e.g., presence of an overflow and/ or tap is not offset from drainpipe). Staff are remined to turn of taps that are not ‘hands free’ with paper towels to keep patients safe.
Frequency of clinical curtain change: Disposable curtains are in use. A risk assessment is in place, defining medium and high-risk areas and the frequency of curtain change required based on the risk level. All curtains are regularly checked and changed if visibly soiled.
Cleaning specifications, frequencies and cleanliness: Cleaning specifications and frequency of cleaning posters are displayed in applicable clinical areas. Separate cleaning specifications and frequency of cleaning are available for clinical rooms, phlebotomy rooms, Treatment, Minor Surgery and LARC rooms. All staff and cleaners work to these specifications.
Training
All staff receive training at induction followed by annual training in infection prevention and control.
Training is delivered via e-learning for health, IPC email updates, nurse forums and ‘TARGET’ training events. Where any site or hand hygiene audit uncovers an additional training need this will be delivered at the earliest opportunity.
Policies
All Infection Prevention and Control related policies are in date for this year. The next review and update for the IPC Policy is due in June 2025.
In addition to the primary IPC Policy the partnership also has 7 IPC Protocols, these are reviewed at the same time as the policy.
- Disinfection and decontamination- Covid 19
- Aseptic non touch and clean technique
- Inoculation and contamination (sharps) injury
- PPE
- Body fluid and spillage
- Obtaining specimens
- Handwashing
- Infection control and good practice for equipment commonly used in the delivery of respiratory diagnostics, monitoring and management in Primary Care
Policies relating to Infection Prevention and Control are available to all staff and are reviewed and updated annually, they are all amended on an on-going basis as current advice, guidance and legislation changes. Infection Control policies are circulated amongst staff for reading and discussed at meetings on an annual basis. All staff can access the policy and associated protocols in the clinical policy storage area on MS teams.
Responsibility
It is the responsibility of each individual to be familiar with this Statement and their roles and responsibilities under this.
Review date
The annual statement will be reviewed and rewritten in March 2026 following the audit cycle.
Responsibility for Review
The Infection Prevention and Control Lead is responsible for reviewing and producing the Annual Statement.
Lucy Pritchard
NMC 06B1099E
Head of Nursing
For and on behalf of Living Well Partnership