Infection Control

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 regarding 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.

Infection Control Annual Statement: – December 2023


This annual statement will be generated each year in December in accordance with the requirements of The Health and Care Act 2022 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 Hedge End Medical Centre has one Lead for Infection Prevention and Control: ALISON JOHNSON (Advanced Nurse Practitioner)

The IPC Lead is supported by: JENNIE DOCK (PRACTICE MANAGER) and team.

The Infection Control Lead attends annual training needs and regular Infection Control Forums delivered by the ICB Primary Care Quality Lead in Lead Infection Prevention and Control Specialist.

 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 are reviewed in the next significant event meeting, attended by GP partners, team leads and management. Those attending the significant event review meetings will agree learning and ensure it is cascaded to all relevant staff.

In the past year there has been 3 significant events (listed below), relating to infection prevention and control. Learning from these events are included:


Incident 1 – Cold chain breach (Vaccines left out)

Multiple vaccines were discovered in a box left on the side in the clean utility room. It was box containing individual named vaccines that the practice buys in for required treatments. This is a locked room so there was no breach of patient identifiable information. The vaccines were removed from potential use and the staff member informed the Practice Manager of her findings.

The investigation concluded that the length of time the vaccines had been out of the cold chain could not be determined, although the manufacturers have all been contacted for advice and guidance as per Infection Control procedure.  The vaccines have been covered in red tape and replaced in the fridge, until replys have all been received from manufacturers.  The likely explanation is that it was left on the side accidentally before the weekend, and the probable action will be to dispose of all the vaccines that are involved in this cold chain breach.


  • Quarantine the vaccines and clearly label them not for use until manufacturers contacted for stability data.
  • Inform Manufacturers clinical teams, NHS England Screening, and Immunisation Team Wessex.
  • Await instruction of disposal or how to use if off label from manufacturers. Label vaccines accordingly
  • Investigate the incident and document all relevant information recorded as a significant event.
  • Feedback at significant event meeting.
  • The relevant staff member was reminded to ensure safe storage of vaccines and the need for replacement immediately into the fridge.
  • The only vaccines to be removed at any one time are the relevant one / ones to the patients need.


Incident 2.- Power failure resulting in a break in the cold chain.

One of the practices’ three vaccine fridges started to alarm. This fridge contained flu vaccines only.  There had been a power cut overnight due to a storm. The Practice Manager was informed by the member of staff who identified this break in power supply first thing in the morning, the day before the fridge temperature had been checked. The data logger was checked to ascertain the time of the temperature excursion, but it was found not to have stored data for the past two weeks. Fortunately, the surgery has three power circuits in the building, each fridge is on a separate circuit. Thanks to our rigorous temperature recording for vaccine storage and stock control only one fridge was affected.  That fridge was isolated, it was established that the maximum length of time was 12hrs. The fridge had remained sealed during that time. The Vaccines were quarantined and clearly labelled not for use and manufactures contacted for stability data.

The advice from the manufacture was to continue to use the vaccines affected by this break in the cold chain, as vaccine efficacy was not compromised. However, the vaccines would now be classed as off label.

An explanation was given to each patient prior to giving the affected flu vaccines advising that the vaccine was off label but had efficacy was unaffected, and the vaccine safe to give. They were also offered written information to take home. Patients were asked to consent to the off-label use of the vaccine.

The vaccine information is recorded on each individual patients notes that the vaccine is off label and patient information has been given. Thus, allowing the patient to make an informed choice of consent.


Incident 3. Live vaccine given to a child under 2yrs of age in the clinical at-Risk category. (Inactivated vaccination should have been given).

The clinician was alerted to this mistake after the event, as the Emis system has an in built safety net system when entering a vaccination into the system prior to giving. The clinician concerned notified the lead nurse and Practice Manager straight away.

The NHS Imms Team was contacted for advice and Mum was contacted by telephone giving the clinical advice from NHS Imms. She was advised to closely monitor the child and what signs and symptoms to monitor for.

A follow-up telephone call was made to give the Mum an opportunity to discuss and to escalate the error should she wish to do so. An email was sent containing written information from NHS Imms Team.


All vaccines should be entered onto the Emis computer system prior to giving.

In future the surgery will not send out AccuRx self-book text messages to children under the age of 2yrs, as they need to be booked with a different clinician in a different clinic.

This incident has been shared as a learning process for the whole Team as part of the Significant Event learning process.



Infection Prevention Audit and Actions

The Annual Infection Prevention and Control audit process was completed by Alison Johnson, Louise Cook, and Jennie Dock in July 2023.

The audits completed this year were as follows:

General Infection Control Audit (including environment, sharps, waste, vaccines, clinical)

Cleaning Audit with the domestic cleaning company.

As a result of both audits, the following things have been changed in Hedge End Medical Centre:

  • Building maintenance planned
  • Decoration and repair of damaged walls to be assessed in the review and prioritised
  • Area’s requiring de cluttering identified.
  • Areas for deep cleaning identified and completed
  • Removal of limescale from all taps in all the rooms.


Hedge End Medical Centre plan to undertake the following audits during 2024

  • Annual Infection Prevention and Control audit (including environment, sharps, waste, vaccines, clinical)
  • Domestic Cleaning audit
  • Audit the decluttering process, in particular to ensure the removal of items under the sinks in each room, if item / items are still required, they are to be placed in a sealed top box.
  • Hand washing Audit.
  • An audit of Post operative infection rate with regards to Coil insertions and Implant insertions/removals.



 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:

  • Management of staff working with confirmed covid-19 infection and presumed Covid 19 Infection.
  • Management of clinical staff during pregnancy
  • Management of Covid-19 infection in the community
  • Regular water testing to ensure that nil Legionella has entered our water systems, with hot and cold temperature checking and recording of all water pipes throughout the practice
  • Immunisation: As a practice we ensure that any staff who will come into contact with body fluids are up to date with their Hepatitis B immunisations and have a good response to titres. If not, risks assessments are carried out. All staff are offered an annual influenza vaccine if they have not been able to receive one at their own GP practice.

We take part in the National Immunisation campaigns for patients and offer routine scheduled vaccinations and seasonal vaccinations in surgery and via home visits to our patient population.

Curtains and blinds: The NHS Cleaning Specifications state the curtains should be cleaned or if using disposable curtains, replaced every 6 months. To this effect we use disposable curtains and ensure that all clinical areas (treatment rooms/minor ops) are changed every 6 months. All curtains are regularly reviewed and changed if visibly soiled. The windows blinds are very low risk and therefore do not require a particular cleaning regime other than regular vacuuming to prevent build-up of dust.

Toys: All toys have been removed since March 2020.

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 manager and Practice Management 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. Some of our sinks do not meet the latest standards for sinks but have had the plugs removed. Staff reminded to turn of taps that are not ‘hands free’ with paper towels to keep patients safe. We have liquid soap with wall mounted soap dispensers to ensure cleanliness and hand gel in the waiting room and clinical rooms.


All our staff receives mandatory training in infection prevention and control. On-line training is available and mandatory for all new staff.

The Infection Control Lead attends annual training needs and regular Infection Control Forums delivered by the Primary Care Quality Lead in Lead Infection Prevention and Control Specialist.

GPs have undertaken specialist training in Minor surgery, infection prevention and control and joint injections. However, due to capacity within the GP clinical Team, minor surgery clinics have been suspended.

GP’s and specially trained nurses have undertaken specialist training in Sexual health with regards to Coil insertions and Implant insertions/removals.

GPs and Practice Nurses attend Target sessions and practice nurse forums that may include topics relating to infection control.


The following policies have been reviewed and updated as appropriately:

  • Primary care infection prevention and control

Policies relating to Infection Prevention and Control are available to all staff and are reviewed and updated on a 2 yearly basis and all are amended on an on-going basis as current advice, guidance and legislation can change. Infection Control policies are circulated amongst staff for reading and discussed at meetings on an annual basis.


It is the responsibility of everyone to be familiar with this Statement and their roles and responsibilities under this.

Review date

December 2024

Responsibility for Review

The Infection Prevention and Control Lead and Practice Manager are responsible for reviewing and producing the Annual Statement.

Jennie Dock

Practice Manager

For and on behalf of the Hedge End Medical Centre.