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:

• 1. 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.
  2. The last cleaning meeting with all cleaners and leads took place on 17.02.2025.
  3. 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 1^st April 2024 to 31^st 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

 

 

Statement of purpose (as of February 2022)

The name and address of the registered provider is:

Thistlemoor Medical Centre
6-10 Thistlemoor Road
New England
Peterborough
www.thistlemoor.co.uk

Registered Manager: Dr. Neil Modha
Practice Manager: Ms. Paulina Janczura
Legal Status: Partnership
Service Types: Doctors Consultation Service
Doctors Treatment Service

Regulated Activities:

Treatment of disease, disorder or injury

Surgical Procedures

Diagnostic and Screening Procedures

Maternity and Midwifery

Family Planning Service

Vaccination services

Service Users:

Open for Registration to patients resident and temporarily resident on the practice area.

The medical centre has existed for over 50 years and started as a single building. The practice has been completely remodelled over its history to now consist of purpose built facility within modern premises. The practice also has large onsite parking. We have been a training practice since 2010.

Due to Coronavirus we have developed an external site for flu and coronavirus vaccination delivery. This involves 3 vaccine cabins towards the rear of the Practice near the Staff Car Park.

Under the Health and Social Care Act 2008 (The Care Quality Commission (Registration) Regulations 2009 Part 4), the registering body (Thistlemoor Medical Centre) is required to provide to the Care Quality Commission a statement of purpose.

Our Aims and objectives:

• Provide a high standard of Medical Care
• Be committed to our patients needs
• Act with integrity and complete confidentiality
• Be courteous, approachable, friendly and accommodating
• Ensure safe and effective services and environment
• To maintain our motivated and skilled work teams
• Through monitoring and auditing continue to improve our healthcare services
• Maintain high quality of care through continuous learning and training
• Ensure effective and robust information governance systems
• Treat all patients and staff with dignity, respect and honesty
• Ensure that every individual is treated fairly and without discrimination

Our purpose is to provide people registered with the practice with personal health care of high quality and to seek continuous improvement on the health status of the Practice population overall. We aim to achieve this by developing and maintaining a happy sound Practice which is responsive to people’s needs and expectations and which reflects whenever possible the latest advances in Primary Health Care.

We aim to offer our registered patient population a service they are satisfied with; our vision statement is “The service we provide is the service we are happy to receive”. If however, you are dissatisfied with the service you receive from any of the Doctors or other member of the Practice team please let us know to enable us to resolve the matter. We operate a practice complaints procedure in accordance with NHS Guidelines.

 

Feedback is really important as it helps us consider ways of improving our service, however we would appreciate some consideration in the way you provide feedback to us.

 

A common approach to the handling of complaints was introduced across health and adult social care. Our complaints procedure is in accordance with this approach. We understand that people may be angry or upset by the issues they raise in their complaints. However, we will not tolerate any violence or aggressive behavior. The NHS has a “zero-tolerance” policy regarding such behavior, which may result in removal from the Practice list.

 

How to make a complaint?

Complaints should be addressed to the Complaints Team. We ask that all complaints are submitted in writing by completing the online complaints form, where possible.

If you do not want to complain directly to the surgery, you can contact NHS England by clicking here

 

When can a complaint be made?
A complaint can be made:
Within 12 months of the incident which is the subject of the complaint

Within 12 months of the subject of the complaint coming to the complainants notice

We request that all complaints are submitted as soon as possible, where possible.

 

Who can raise a complaint?

The Practice adheres to the strict rules in place relating to patient confidentiality. If you are complaining on behalf of someone else, we need to have their permission for you to do so. A consent form signed by the patient concerned will be required by the Practice, unless they are incapable of providing this.  Where the patient is a child, either parent or legal guardian of the child can raise a complaint on their behalf.

 

How long does it take to resolve a complaint?
We aim to acknowledge your complaint within three working days and resolve your complaint within 30 days of the date the complaint was received.  However, depending on the complexity of the complaint, it may sometimes take longer. In such instances, you will be informed.

 

Not satisfied with the response?
If you are not satisfied with the response to your complaint, you can contact us to request for further clarification or a meeting with the Complaint Team where we will attempt to address outstanding concerns.  If this process does not resolve your concerns to your satisfaction, you can contact the Parliamentary and Health Ombudsman, who can undertake an independent review of your complaint. www.ombudsman.org.uk  or telephone 0345 015 4033

 

You can also contact a local Health Advocacy Service who can provide advice and support through the complaint process, such as www.pohwer.net/peterborough or your local Integrated Care Board (ICB) Cambridgeshire & Peterborough ICS Patient Experience Team

 

Contact Details

Complaints Team
Thistlemoor Medical Centre
6-10 Thistlemoor Road
Peterborough
PE1 3HP

Tel: 01733 551988

Email@ admin@thistlemoor.nhs.net

The NHS operates a zero tolerance policy with regard to violence and abuse and the practice has the right to remove violent patients from the list with immediate effect in order to safeguard practice staff, patients and other persons.

Violence in this context includes actual or threatened physical violence or verbal abuse which leads to fear for a person’s safety. In this situation we will notify the patient in writing of their removal from the list and record in the patient’s medical records the fact of the removal and the circumstances leading to it.

We believe that it is important to protect our staff and other patients or visitors.

We understand that the pandemic has been challenging, and recognise that many of us are struggling as a result of this. However, this is no reason for you or your carers to be rude, abusive or racist to us or out staff. If this happens – you will be written to to explain that this behaviour is unacceptable, this will be your final warning. If this happens twice, we will write to our commissioners and ask for your registration with the practice to be cancelled.

A simple guide – is please treat us the way you would like to be treated.

In order to provide care for you, we are obliged to keep records. We are a computerised practice and we comply with the Data Protection Act 1998 and other guidance on privacy and data confidentiality. In order to manage services and improve the quality of care we provide, we share some information on practice activity e.g. with The clinical commissioning group.

Wherever possible, the information is anonymous i.e. names and other identifying details are removed.

Information is NOT shared with any third party outside the Health Service (e.g. insurer, employer, and solicitor) without explicit consent and agreement. We are obliged by law to provide certain information e.g. notification of infectious diseases to Public Health Specialists.

Everyone working for the NHS has a legal duty to keep information about you confidential and adhere to a Code of practice on protecting patient confidentiality.

If you would like access to your medical records, please apply in writing to Paulina Janczura, Practice Manager.

What if I want to discuss my concerns about a family member or friend who is registered at your practice?

If you have serious concerns about a registered patient, please do not hesitate to let us know.

However, to respect out patient’s confidentiality we are unable to discuss the contents of any patient’s records with a family member or friend without written consent from that patient allowing us to do so.

The exception to this is when a parent wishes to discuss their child’s health. If a child under 16 consults about contraception, the parent is not entitled to access that information, although it is accepted practice for the doctor or nurse to encourage the child to discuss the contraception with his or her parents / guardian.

General practices are required to publish the average earnings per General Practitioner for the year 2020/2021.

For Thistlemoor Medical Centre, the average earnings per GP is £77,800. This is based on 7 Full-time and 8 Part-time Doctors and takes into account NHS income against expenses without deductions of Tax or national insurance.

At our medical centre we aim to provide our patients with the best quality care available. Our charter is a statement of what you can expect from this practice and what we feel we can expect in return from you.

All patients will be treated equally. We do not discriminate on the grounds of gender, gender identity, race, disability, sexual orientation, religion or age.

Our premises will be clean and comfortable and have facilities for the disabled

All patients will be greeted in a friendly manner and be treated with courtesy by everyone in the practice.

Strictest confidentiality should be expected.

Patients will be offered advice about how to stay healthy and avoid illness

New patients registering with the practice will be offered a health check

Patients will be referred to a specialist when the doctor feels this is necessary

Complaints will be dealt with by our complaints manager who will refer complaints to the doctors where appropriate

We Aim

• To offer patients a consultation with a healthcare professional within 24 hours during the working week. Due to the current coronavirus pandemic this will be mainly delivered by the telephone or video consultations.
• To see all patients with genuine urgent problems as soon as possible.
• To provide appointments in the afternoon for patients. Although patients should understand that for routine appointments there may be a wait of several days or weeks.

Policy On Patients’ Rights

In relation to primary care, patients have certain rights.

A patient has the right to;

• be on a practice list
• have a consultation with a clinician (this depends on availability and does not need to be their named GP) at the medical centre. Nurses can manage many of the conditions previously managed by GP’s and are the first port of call for many patients. If a nurse cannot manage the condition they will discuss this with their supervising clinician.
• have access to a telephone number where a signposting service can be reached 24 hours a day, every day of the year. This should preferably be a home telephone number.
• have a home visit if the patient lives within the practice boundary, if considered necessary by the GP.If temporarily away from home must receive treatment if it is considered to be required immediately, though the GP is not bound to accept them as a temporary resident.
• be prepared to wait for an appointment. Routine appointments may need a wait of more than 15 days depending on the demands on the service.
• change practice, by applying to another practice. No reason is required
• be entitled to a chaperone during examinations
• not bound legally to accept treatment. However, a doctor can give essential treatment if the patient is temporarily incapable of understanding or consenting to treatment as per the Adults with Incapacity Act
• refuse to be examined when a medical student or other trainee is present
• be entitled to a full and truthful answer to questions unless the answers would result in anxiety, which may injure the person’s health
• complain about their GP if he has not followed his terms of service or behaves in an unprofessional or unethical way. The patient should then be kept informed about how the complaint is being dealt with and told of the outcome
• see medical reports requested by insurance companies or employers before they are forwarded. However, a GP may withhold them if access may cause harm to the patient or if they contain information regarding a third party
• confidentiality

With These Rights Come Responsibilities

We ask that patients attend their appointments at the arranged time. If they cannot attend they will inform the medical centre immediately

We expect that patients will understand that appointments are for one person only. Additional appointments will be made if more than one person needs to be seen

Patients are responsible for their own health and the health of their children and should co-operate with the practice in endeavouring to keep themselves healthy

We ask that requests for help or advice for non-urgent matters be made during surgery hours

Home visits should only be requested for patients who are seriously ill and live within the practice boundary. It is important to bear in mind that most medical problems are dealt with more effectively in the clinical setting of a well-equipped medical centre.

Patients should understand that home visits are made at the doctor’s discretion

Many problems can be solved by advice alone, therefore patients should not always expect a prescription at every consultation

We ask that patients treat the doctors and staff with courtesy and respect.

Patients must inform the practice staff of any alterations in their circumstances, such as change of surname, address or telephone number, even if it is ex-directory

We ask users of the service to be patient, to expect a waiting time in our morning surgeries and to be prepared to wait several days for a routine appointment. This allows us to prioritise care for those who are most in need of medical attention.

We ask our patients to understand the rise in demand for general practice services and understand the difficulties in recruitment that can lead to pressures on our service and longer waiting time for emergency and routine appointments.

Suggestions

We welcome comments on the services provided. These should be directed to one of the partners or to the practice manager, Ms Paulina Janczura.

 (Updated August 2021)

Read/Download our Privacy Notice

Read/Download our Data Protection Impact Assessment (DPIA) Policy

Statement

The recording of data within the practice is under the management and control of Dr Nalini Modha, who is the Clinical Governance and IT lead GP for the practice.

The quality of data, the use of templates and the use of specific coding is reviewed on an ongoing basis and the findings are discussed at weekly clinical policy meetings, where examples of coding issues are cited as appropriate.

Dr Nalini Modha and Dr Neil Modha is responsible for overall coding and data quality issues within the practice and will ensure accuracy and consistency in coding among both the clinicians and the administrative or casual staff.

Agnieszka Soczowka is the non-clinical manager responsible for audit and exception identification and reporting within the practice.

This responsibility is supported by frequent audit and validation of data using QOF and other tools, and is supported by a data administrator employed for this purpose.

The Clinical System, SystemOne is responsible for distributing updates Read / SNOMED codes as and when they become available.

Any queries should be addressed to the lead GP.