Infection Control Statement

The Ridgeway Surgery – Infection Control Annual Statement Report



This annual statement will be generated each year in February, 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. The report will be published on the organisation’s website and will include the following summary:

  • 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 carried out and actions undertaken
  • Details of any risk assessments undertaken for the 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 lead for infection prevention and control at The Ridgeway Surgery is Judy Moran, Practice Nurse. 

The IPC lead is supported by Ella Thompson. Practice/Business Manager. 

  1. Infection transmission incidents (significant events)

Significant events (or learning events) involve examples of good practice as well as challenging events.

Positive events are discussed at meetings to allow all staff to be appraised in areas of best practice.

Negative events are managed by the staff member who either identified or was advised of any potential shortcoming. This person will complete a Significant Event Analysis (SEA) form which commences an investigation process to establish what can be learnt and to indicate changes that might lead to future improvements.

All significant events are reviewed and discussed at several meetings each month. Any learning points are cascaded to all relevant staff where an action plan, including audits or policy review, may follow.

In the past year, there have been zero significant events raised which related to infection control. There have also been zero complaints made regarding cleanliness or infection control. 

  1. Infection prevention audit and actions

We have undertaken the following Infection Control Audits in the past year:

Minor surgery room audits – completed monthly
Infection Control annual audit – last completed 19.8.2023
Infection Control quarterly audits – last completed 1.11.2023
Hand hygiene audit – 23.1.2024

Any ACTIONS from the audits:

Cold Chain audit completed January 2023
Replacement chairs ordered for 3 rooms
Pedal operated general waste bins ordered for all rooms
Sample trays purchased
New blinds ordered for clinical rooms

A monthly cleaning audit is completed by the cleaning contractor, Lawrence Cleaning.  A full audit is completed by quarter by the cleaning contractor, Lawrence Cleaning.

A deep clean of the carpeting at the surgery took place on 20.1.2024.

  1. Risk assessments 

Risk assessments are carried out so that any risk is minimised and made to be as low as is reasonably practicable. Additionally, a risk assessment that can identify best practice can be established and then followed.

In the last year, the following risk assessments were carried out/reviewed:

  • Bodily fluids, blood, vomit and urine
  • Fridge maintenance
  • Legionella
  1. Training

In addition to staff being involved in risk assessments and significant/learning events, at The Ridgeway Surgery all staff and contractors receive IPC induction training on commencing their post. Thereafter, all staff receive refresher training annually.  The Infection Control Lead, Judy Moran, has attended Infection control update training throughout the past year.

  1. Policies and procedures

The infection prevention and control-related policies and procedures that have been written, updated or reviewed in the last year include, but are not limited, to:

            Infection, prevention and control handbook
            RWM21 Infection Control Policy v5.1
            RWA40 Clinical Waste Policy v3

Policies relating to infection prevention and control are available to all staff and are reviewed and updated annually. Additionally, all policies are amended on an ongoing basis as per current advice, guidance and legislation changes. 

  1. Responsibility

It is the responsibility of all staff members at The Ridgeway Surgery to be familiar with this statement and their roles and responsibilities under it. 

  1. Review

The IPC lead and Practice Manager are responsible for reviewing and producing the annual statement.

This annual statement will be updated on or before 9.2.2025.


Signed by

Ella Thompson

For and on behalf of The Ridgeway Surgery