Infection Control Policy

Infection Prevention and Control Annual Statement

Purpose

This 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.  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

Bethesda Medical Centre Lead for Infection Prevention and Control is Fleur McSweeney (Practice Nurse).  The Infection Prevention Control Lead is supported by Rachael Cousins (Practice Manager).

Fleur McSweeney has undertaken regular training and updates on IPC and has attended the Wessex LMC IPC update on 18 October 2022.

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 at the quarterly Significant Event meeting and learning is cascaded to all relevant staff.

In the past year there has been no significant events raised that related to infection control.  There was also no infection significant events raised in 2023.

Infection Prevention Audit and Actions

The Annual Infection Prevention and Control audit was completed by William Pillow from the Infection Prevention and Control Team at Infection Prevention Solutions, and was accompanied by Fleur McSweeney on 05/04/2024.  The following audit was undertaken on 04/04/2025, and the next audit is scheduled for March 2026.

Bethesda Medical Centre undertook the following audits in 2025:

• Annual Infection Prevention and Control audit
• Cytology Audit
• Handwashing of clinical staff
• Cleanliness of Bethesda Medical Centre equipment
• Monthly clinical room cleaning audit (ground floor)
• Effective use and documentation of Bethesda Medical Centre equipment
• Prescribing audit
• Childhood immunisations
• Vaccination programmes – Pneumococcal, Shingles, RSV, MMR catch-up, Covid-19 and Influenza.

We have been able to offer more appointments since 2025 for cervical screening, childhood immunisations and adult vaccination programmes.  We regularly send invites to patients to book appointments either via messaging, letter or phone calls.  We work closely with Andrea Nemethy who works for the PCN to increase the uptake of childhood immunisations.  We have done some home visits to vaccinate children who have been overdue vaccinations to ensure they are up to date with the UK vaccination schedule.  We do a shingles/pneumococcal/RSV vaccination clinic every six months.  During the influenza season we offer Saturday appointments as well as early morning and evening appointments in addition to our normal clinics to help maximise the uptake of the vaccination programme.

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: - Bethesda Medical Centre has conducted and reviewed its water safety risk assessment to ensure that the water supply does not pose a risk to patients, visitors, or staff.
• Immunisation: - As an Organisation we ensure that all of 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).  Bethesda Medical Centre encourage all employees to have the COVID 19 vaccinations as recommended by the Department of Health for Primary Care.
• Communicable diseases – All staff are able to risk assess whether a patient may require isolation to prevent transmissible infection. Where appropriate a telephone call would be offered but if a patient does need to attend the surgery they will asked to isolate in our primary isolation room in the West Wing.

Other examples

Bethesda Medical Centre has recently had their clinical rooms flooring changed to remove the carpets.  We now have 23 clinical rooms with the correct clinical flooring.

Following guidance, all clinical rooms have been updated to ensure that they now have a soap dispenser on the wall that require single use soap cartridges (non-refillable).  Sharps boxes have been put onto brackets on the walls and clinical waste bins have been changed.  We have also replaced all chairs in clinical rooms to ensure that they are all wipeable.

Assura have recently replaced the air conditioning units in all consulting rooms ensuring the removal of fans and electric heaters.  This also ensures windows do not need to be opened during minor surgery to prevent any external infection control (e.g. flies).

Cleaning specifications, frequencies, and cleanliness

Bethesda Medical Centre's designated lead for cleaning and decontamination of the environment is Med Clean South, and we also have an in-house domestic team.  Both teams have cleaning specification and frequency policies which their cleaners and staff complete regularly.  A spot check assessment of cleanliness is conducted by the Practice Manager/cleaning team and logged on schedules.  This includes all aspects in the surgery including cleanliness of equipment and the responsibility of the property owners. The surgery has a cleaning schedule adapted to cover the cleaning and decontamination of clinical and treatment rooms,  and also covers the communal and other areas of the surgery.

We adhere to our COSHH policy, which is updated every time a new COSHH product is used within the surgery.

Minor Surgery/Family Planning is only carried out in Treatment Room 2 where there is an air exchange fan to ensure clinical procedures are untaken in a cleaner air environment.  Wound care is only carried out in Treatment Room 1.

Training

All Bethesda Medical Centre staff members receive annual training in infection prevention and control.  All Staff undertake online training with Invicta Health Training within the first 3 months of employment.  An IPC training session was delivered for all staff in November 2024 Infection Prevention Solutions.  Anyone unable to attend received the shared presentation slide resources.

All surgery staff understand the importance of Infection Control and Prevention and understand the importance of annual training.

IPC Policies, procedures and guidance

All Infection Prevention and Control related policies are in date for this year.

Policies relating to Infection Prevention and Control are available to all staff, are reviewed, updated annually, and all are amended on an ongoing basis as current advice, guidance, and legislation changes.  Infection Control policies are circulated amongst staff on our Teamnet system for reading and discussion at meetings on an annual basis.

Antimicrobial prescribing and stewardship

Bethesda Medical Centre have yearly audits on prescribing of antibiotics.  We also receive data from the IPC on our prescribing compared to local and national surgeries.  Our prescribing lead is Dr Manoj Jha and any concerns about prescribing are discussed with him.  Ross McSavaney is our in-house Pharmacist, Scott Baldock is our in-house Pharmacy Technician, and Lesley Sturges is the Pharmacy Technician for the Care Home Team within the Primary Care Network.

Our prescribing team follow local polices and national guidance such as NICE when prescribing antimicrobials.  They are able to contact microbiology if they need advice on antimicrobials.

Bethesda Medical Centre do not always issue antibiotics to be dispensed on the day of the prescription.  We issue delayed prescriptions and plan to raise awareness of World Antimicrobial Awareness Week from 18-24th November each year.

Microbiology covers diagnosis, treatment, management and prevention of infectious diseases.  East Kent Hospitals Microbiology's discipline is United Kingdom Accreditation Service (UKAS).  Our local hospital where all specimens are sent to is William Harvey Hospital.

Responsibility

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

Bethesda Medical Centre ensure that all policies and protocols are circulated to Staff on TeamNet and are re-circulated when an update has been amended.  We also update our website with information on our commitment to Infection Control and Prevention and offer patients to provide positive or negative feedback.

All staff adhere to 27 Infection Prevent and Control Polices that we have adopted from Infection Prevention Control Solution.  These policies are reviewed yearly and circulated to all team members.

Bethesda Medical Centre carry out risk assessments on staff to ensure they are up to date with their immunisations.

All new staff have an appointment with Occupation Health via EKHUFT prior to starting to ensure they are up to date with their immunisations.

Review date

March 2026

Responsibility for Review

The Infection Prevention and Control Lead is responsible for reviewing and producing the Bethesda Medical Centre Annual Statement.

Updated 12/03/2025