Annual Infection Prevention & Control Statement
Chapelfield Medical Centre, Mayflower Way, Wombwell
Date of Statement: 26.03.26
Review Date: 26.03.27
1. Introduction
This annual statement has been prepared in accordance with the requirements of the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and the requirements of the Care Quality Commission and relevant national guidance on infection prevention and control within primary care settings.
Chapelfield Medical Centre is committed to maintaining a safe environment for patients, staff and visitors through effective infection prevention and control (IPC) procedures. The practice follows national guidance and best practice to reduce the risk of healthcare-associated infections.
This statement summarises:
- IPC arrangements within the practice
- IPC training and education
- Audit and monitoring activity
- Significant events relating to infection control
- Plans for improvement for the coming year
This statement will be made available to patients and the public on request and via the practice website where applicable.
2. IPC Leadership and Responsibilities
The practice has appointed a lead for infection prevention and control who oversees the implementation of IPC policies and procedures.
IPC Lead:
Marta Szczesna – Practice Nurse
Supporting Clinical Lead:
Angela Bywater – Lead Nurse
Responsibilities include:
- Oversight of infection prevention and control policies
- Monitoring compliance with national guidance
- Coordinating IPC training for staff
- Leading infection control audits
- Investigating incidents relating to infection control
- Reporting findings and improvements to the practice management team
All staff members share responsibility for maintaining high standards of infection prevention and control.
3. Infection Control Policies
Chapelfield Medical Centre maintains up-to-date IPC policies and standard operating procedures, which are reviewed regularly and updated in line with national guidance. They have all been updated and reviewed this year by A Bywater Lead Nurse.
These include policies relating to:
- Hand hygiene
- Personal protective equipment (PPE)
- Safe management of clinical waste
- Decontamination of medical equipment
- Cleaning standards for the premises
- Management of blood and body fluid spillages
- Management of communicable diseases
- Needlestick injury management
- Sharps safety
Policies are accessible to all staff and will be reviewed regularly between 1 – 3 years or sooner if national guidance changes.
4. Staff Training
All staff receive appropriate infection prevention and control training relevant to their role. This is updated yearly by online training.
Training includes:
- Hand hygiene
- Standard infection control precautions
- Use of personal protective equipment
- Sharps safety
- Training is provided during induction and through regular updates.
Training Compliance (example – modify annually):
- Clinical staff IPC training completion: 1 clinical staff member is overdue
- Non-clinical staff IPC awareness training: 2 non-clinical staff members are overdue, one of whom is on maternity leave
Training records are maintained and monitored by the practice management team via practice index hub.
5. Audits Undertaken
Regular infection control audits are undertaken to ensure compliance with standards.
Examples of audits include:
- Hand hygiene audits, this is a rolling monthly audit
- Cleaning audits, are carried out monthly by the cleaning supervisor
- Waste management audits, carried out yearly
- Sharps safety audits, carried out quarterly
- Equipment decontamination audits, spot checks/audits carried out weekly
Findings from audits are reviewed by the IPC lead and Lead Nurse and discussed with the practice team. Any identified issues are addressed through an action plan.
Summary of Audit Results:
Yearly Full IPC audit carried out February 2026 and scored 91.17%, improvement needed in segregation of sharps, displaying of posters for application of PPE, supply of tissues and maintenance of staff vaccination register.
Monthly hand hygiene audits, this is a rolling audit to capture all staff through the year. Compliant.
Monthly PPE audit, this is a rolling audit to capture all staff through the year. Compliant.
Weekly spot checks/audit of room decontamination and waste segregation. Generally compliant with minor improvement needed, EG, one staff clinical staff member being out of ate with IPC training, reminded to complete
6. Changes made because of the audits:
When the clinical rooms have been decontaminated at the end of the day, ‘I am clean stickers’ are utilised, and the cleaning schedule is signed by each clinician.
New patient chairs for the waiting room, clinic rooms and some clinician chairs have been obtained due to wear and tear.
I heart side of the building has been redecorated and new flooring has been laid; we are hoping to roll this out to the rest of the practice in the coming months.
New microwave, fridge and bins have been bought to replace ones with signs of wear and tear.
7. Significant Events
Significant events relating to infection prevention and control are recorded, reviewed and investigated.
During the reporting period:
- Number of IPC related incidents: 4
- Actions taken: Completed Significant event, discussed and fed back as appropriate
Learning from these events is shared with staff to improve practice and prevent recurrence. We need to re starting having significant event meetings.
8. Cleaning and Environmental Hygiene
The practice has a cleaning schedule in place which ensures all areas are cleaned to an appropriate standard. This follows that National Standards of Healthcare Cleanliness, updated 2025.
Cleaning is undertaken by:
- A contracted cleaning service and is in keeping with the National recommendations
Cleaning schedules include:
- Daily cleaning of clinical areas
- Regular deep cleaning where required
- Monitoring and review of cleaning standards, auditing monthly
9. Waste Management
Clinical and non-clinical waste is managed in accordance with national guidelines.
The practice ensures:
- Correct segregation of waste streams
- Safe disposal of sharps
- Use of licensed waste contractors
- Appropriate storage and collection arrangements
10. Antimicrobial Stewardship
The practice supports responsible prescribing of antibiotics to reduce antimicrobial resistance.
Prescribing practices are monitored through:
- Prescribing audits
- Review of prescribing patterns
- Adherence to national and local prescribing guidelines
11. Plans for the Coming Year
The practice will continue to improve infection prevention and control standards.
Planned actions include:
- Continued IPC training updates for all staff
- Ongoing infection control audits
- Review and update of IPC policies
- Monitoring cleaning standards and environmental safety
- Review of antimicrobial prescribing practices
12. Review
This statement will be reviewed annually and updated as required to ensure continued compliance with guidance from the Care Quality Commission and national infection control standards.
Written by: Angela Bywater, Lead Nurse
Approved by:
GP Partners
Date:
09/04/26