Infection Control Statement


This annual statement will be generated each year in November 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 practice 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 undertaken 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 Jane Hughes, practice nurse.

The IPC Lead is supported by Ella Thompson, practice/business manager.

a. Infection transmission incidents (significant events)

Significant events involve examples of good practice as well as challenging events.

Positive events are discussed at meetings to allow all staff to be appraised of 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 that 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 in 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 has been 1 learning/significant events raised that related to infection control. This related to ensuring the safe acceptance of sharps boxes from patients during the current pandemic and was dated 17.6.2020. There have not been any complaints made regarding cleanliness or infection control.

b. Infection prevention audit and actions

Our external IPC audit has been delayed due to the current pandemic.

Actions raised by the IPC audit in September 2017 have been addressed.

An IPC audit checklist was performed on 11.11.2020 and will be completed annually.

Environmental cleanliness audits are conducted weekly.

A review of cleaning standards has been completed with our cleaning contractor which has resulted in additional time for the cleaners to carry out allotted to carry out cleaning duties.

The “Care Setting Process Improvement Tool” will be completed shortly. This provides and detailed IPC audit and will be conducted annually on years when we do not have a IPC PHE audit.

c. Risk Assessments

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

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

  • COSHH – completed – new data sheets required and now provided
  • Body Fluids, Blood, Vomit & Urine – reviewed
  • Covid19 – completed and reviewed, ongoing (included removal of toys and magazines from waiting room)
  • Fridges – reviewed and updated
  • Kitchen – reviewed
  • Legionella – 2 yearly RA completed – actions addressed
  • Infection control audit checklist
  • Cleaning standards
  • Healthcare associated infections – HCAIs and occupational infections – no HAI have been reported
  • Minor surgery – log kept for infections relating to infection control – none reported
  • Sharps – no sharps injuries reported
  • PPE – PPE reviewed in accordance with COVID19 guidance and used appropriately by all staff. As guidelines change we have adapted, eg wearing of masks and social distancing by all staff.
  • Risk of body fluid spills – should a sample or blood be spilt there are spillage kits onsite

d. Training

In addition to staff being involved in risk assessments and significant events, at The Ridgeway Surgery all staff and contractors receive IPC induction training on commencing their post. Thereafter, all staff receive refresher training annually. Infection control training is part of the induction training module completed by all new staff.

e. Policies and procedures

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

  • RWM21 Infection Control Policy V5.0 – policy rewritten in accordance with national guidance
  • 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


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.


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

This annual statement will be updated on or before 11.11.2021

f. Infection control advice to patients

Under COVID19 IPC guidelines patients are:

  • Telephone triaged for symptoms before they can attend the surgery
  • Asked to wear a mask/face covering
  • Entrance and exit points are separate
  • Asked to use hand sanitiser upon entering

IPC advice has been displayed on our website and regularly on social media.

IPC statement completed by:

  • Jane Hughes – practice nurse, IPC lead
  • Ella Thompson – practice/business manager

For and on behalf of The Ridgeway Surgery.