Annual Statement of Infection Control updated April 2025
Purpose
An annual statement is generated each year in April. The next annual Statement is due in April 2026.
The aim of this statement is to provide an update since last statement, which includes further evidence in the following topics:
- Any infection transmission incidents and any action taken (these will have been reported in accordance with our Significant Events Reporting procedures).
- Details of any infection control audits undertaken and actions taken.
- Details of any infection control risk assessments undertaken.
- Details of staff training.
- Any review and update of policies, procedures and guidelines.
Background
The infection prevention and control Clinical lead for Thistlemoor Medical Centre is
Dr Nalini Modha. The infection Control Nurses lead is Emilia Wierzbicka can be contacted for general queries for Nurses.
The Administrative leads are Roszia Bi, Rachana Khatri, Paulina Piatkowska and Monika Klosowicz.
Significant events
There have been no significant events related to infection control reported since the last annual statement.
All significant event documentation is maintained and reviewed by the Practice Manager, Paulina Janczura.
These documents are regularly reviewed and discussed during clinical and practice meetings with all staff.
Audits
The main team responsible for completing the audits is Monika Klosowicz and Paulina Piatkowska supported by Roszia Bi and Rachana Khatri.
The purpose of these audits is to ensure that all clinicians are disposing of clinical waste products in accordance with statutory regulations, and to re-assess the positioning of sharps boxes to confirm they are not accessible to children.
The last audit was conducted in January 2025.
All sharps box locations were found to be appropriate and safe and did not require relocation.
The audits are repeated at three monthly intervals to ensure good practices are maintained on a daily basis by all clinicians and staff members.
The audits which involve checking consulting and treatment rooms are completed on a monthly schedule and they have been carried out by Monika K.
Toilets are checked in the morning and cleaned at mid-day after morning surgery and a full cleaning of these premises are performed out of hours daily.
The clinical evidence carried by the responsible members are kept up to date and for reference their folders may be checked.
In all room and utilities areas Hand wash Hygiene Technique data sheet were checked and replaced when necessary due to poor state of repair.
A hand sanitizer was supplied to clinicians for their visiting bags for home visit.
Risk Assessments and outcomes
Risk Assessments are carried out to ensure that the practice can review potential risks and ensure that steps are taken to minimise the impact of these risks.
Our infection control lead carried out an infection control inspection in January 2025 when the quarterly internal audit would have taken place.
The cleaning is outsourced to a company called Thorokleen. Catherine is the supervisor in charge of the team of cleaners who is responsible for cleaning the Practice. Regular meetings are held with the cleaning supervisor and Rachana Khatri and the management team based on evidence of cleaning issues identified by the infection prevention and Control team. We have meetings every Wednesday with Catherine Horseman. Rachana and Catherine liaise regularly depending on the cleaning feedback received from staff.
The following actions were needed:
- Proper cleaning of rooms in some areas with further supervision required:
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- Action Plan: the cleaner’s supervisor – Catherine was to complete and supervise the general audit as per job specification in the general cleaning process of those areas.
- The last cleaning meeting with all cleaners and leads took place on 17.02.2025.
- Attendees at the meeting were: Catherine, Rachana and Juta, Elzbieta, Gherghina, Dorata and Alex.
Topics discussed were as follows:
- Cleaners were instructed that they are now required to set the alarm and lock the building each evening after completing their cleaning.
- As cleaners leave the site, they must post a message in the group chat so that when the last cleaner is on-site, they will know they are responsible for setting the alarm and locking the building.
- Training was provided to all cleaners, showing them how to set the alarm and the instructions for leaving the building and locking the door in Zone A.
- Door keys and fobs were allocated to Juta, Gina, and Alex.
Legionella Risk Assessment at Thistlemoor Medical Company is undertaken by a company ‘Yes! Results’.
The responsible person at Thistlemoor Medical Centre is Administrator is Rachana Khatri, Roshani Parmar and assisted by Sai Konte.
The Risk Assessment was done on 09/11/2023 and its next inspection is due to be in November 2025 (review due is 08/11/2025).
Legionella risk assessment and actions taken document together with the risk assessment are available in the evidence folder for Infection prevention and control.
For evidence and reference the physical folder is ought to be consulted with Rachana Khatri. All recommendations are in place and working fully.
Action Plan from last Risk Assessment: a meeting with Rachana Khatri to check the full documentation was in place.
- Legionella Risk Assessment Protocol has been reviewed in November 2023. The next review is planned in November 2025.
- Safe Water Policy has been reviewed in August 2023. The next review is planned in August 2025.
Waste Management
The practice has a comprehensive waste management policy to ensure the safe handling, segregation, and disposal of waste in compliance with regulations. Clinical waste is collected every fortnight by Clini Waste, while domestic waste is collected monthly through a contract with a third party company. Confidential waste is stored securely in a locked console and is collected once a month. Cardboard and non-confidential paper waste are shredded monthly by an external company.
All staff members are responsible for the safe management and disposal of waste. They are trained to understand the proper segregation and storage procedures. The practice is committed to ensuring the health and safety of employees and others who may be affected by the storage, handling, or disposal of waste. Disposal methods and record-keeping must comply with both legislation and best practices.
Staff who handle clinical waste are trained on the associated risks and the correct procedures for safe handling, segregation, and storage. This training also includes instructions for managing spills, and staff members receive annual COSHH training relevant to their roles.
To further ensure safety, a COSHH Assessment was conducted to guarantee that cleaners were fully informed about storage arrangements, first aid, and personal protective equipment (PPE), as outlined in Appendix V. The most recent COSHH Risk Assessment was completed by Roszia Bi and Catherine in January 2025. The next assessment is planned for January 2026, and Roszia Bi/Catherine will be responsible for completing it.
Staff training
Infection Control and Health & Safety Training sessions are conducted regularly to ensure all staff, both new and current, are familiar with the latest protocols and guidelines. These sessions cover essential topics such as infection control, health and safety, and emergency response procedures. The training is typically delivered through general staff meetings, with some specialized topics such as fire safety also including mandatory online training modules.
The purpose of these training sessions is to maintain a safe, hygienic, and efficient working environment for both staff and patients. Regular updates ensure that all team members adhere to best practices and stay compliant with the most current regulations or guidelines.
Recent Staff Training Sessions:
Training Delivered by Dr Neil Modha
- 13/12/2024 – General Meeting:
- Hand Washing: Techniques for effective hand hygiene to prevent the spread of infection.
- Needle Stick Injury: Protocols for managing and responding to needle stick injuries.
- Chain of Infection: Understanding how infections spread and methods to break the chain.
- Personal Protective Equipment (PPE): Correct use and disposal of PPE to ensure safety and hygiene.
- Spillage Protocol: Procedures for managing and cleaning up hazardous spills.
- 18/07/2024 – General Meeting:
- Fire Procedures: Safety protocols, including evacuation procedures and the use of fire extinguishers.
- Hand Washing: Reinforcement of proper hand hygiene practices.
- Clinic Room: Expectations for maintaining cleanliness and organization within the clinic.
These training sessions are integral to ensuring that all staff are equipped with the knowledge and skills necessary to maintain a safe and hygienic environment in the practice. Topics such as infection control, needle stick injury management, PPE usage, and fire safety procedures are reinforced regularly. These ongoing training efforts help guarantee the highest standard of care and safety for both staff and patients.
PPE (Personal Protective Equipment)
The practice provides PPE for all members of the team in line with their role.
- PPE audits completed by Roszia B and Paulina Piatkowska in January 2025 were done throughout and quarterly during the period of 1st April 2024 to 31st March 2025 and this is continued in 2025-2026 by Paulina P and Monika K.
- Evidence is available for reference in the Infection Control Audit Folder.
- We discussed PPE with the staff on the Practice Meeting on 13/12/2024
Fixtures, Fittings & Furniture
- Seating audit completed in July 2023. Monthly checks being done by Stanley.
- Waiting area chairs / couches that needed repair have been repaired and maintained during monthly checks. Currently there are no chairs for replacing since last replacement.
Patients
- There have been no reported cases of MRSA acquired in the practice since last annual statement.
- In regards to minor surgeries done in the surgery there are no reports of infection, uterus perforation on bleeding as a consequences of the procedure.
Policies, procedures and guidelines
All policies, procedures are in Health & Safety Folder and Infection Prevention Control Folder.
Responsibility for ensuring its policies and protocols is followed: Dr Nalini Modha and the infection control team and every staff member.
Catherine Horseman from the Cleaning Company Thorokleen is responsible for regular monitoring of the standard of cleaning throughout the practice and reporting to the cleaners if any problems are identified.
Catherine Horseman is responsible for liaising directly with the cleaners alongside Clinical Manager Dr Nalini Modha who will be informed if any issues are identified which need further escalation.
Our Annual Statement of Infection Control is uploaded onto our practice website:
Annual Statement of Purpose and Infection Control 2024-2025.
Next Annual Statement due: April 2026
Team Responsible: Dr Nalini Modha, Rachana Khatri, Roszia Bi, Paulina Piatkowska, Monika Klosowicz