IPC Annual Statement Report

BRAMBLEHAIES SURGERY, CULLOMPTON

MAY 2026

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. 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 Bramblehaies Surgery is Nicki Bere, lead Nurse.

The IPC lead is supported by Tracey Worley, Practice Manager.

Nicki Bere keeps updated on infection prevention practice by attending regular RDUH Primary Care Infection Control Link Network meetings and training updates, having completed Infection Prevention and Control levels 1 and 2

          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 at practice and clinical 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 significant event raised that related to infection control and led to liaison with the UK Health Security Agency and local microbiology team. The practice has recorded this as a significant event, which led to a plan for the future.
• There have also been 0 complaints made regarding cleanliness or infection control.

          Infection prevention audit and actions

The 6 monthly Infection Prevention and Control audit was last completed by Nicki Bere in May 2026.

The infection control risk register is a live document which is added to and updated after each audit, and any changes within the practice (for example the planned internal building upgrade to the nurse rooms- Summer 2026)

As a result of audit, the following has changed in Bramblehaies Surgery;

• New baby changing mat has been bought for patient use.
• Clearing of under sink cupboards has been completed.
• Stains in the flotex flooring have been treated. This was in addition to the cleaning which is done every 6 months by contractor.
• Cleaners and staff have been reminded not to store cough roll on the floor
• Handwash audit completed annually with all staff being sent the video to their E-learning account. This is added to Teamnet for staff acknowledgement.

Bramblehaies Surgery plan to undertake the following audits in 2026/27;

• 6 monthly infection prevention and control Audit
• Hand hygiene audit and staff update.
• 3 monthly room audits which are completed by the cleaning company.
• All sharp bins no longer have a 3-month date to use but must not be filled to more than ¾ full.
• Internal audits are available to view on teamnet.

          Risk assessments 

Risk assessments are carried out so that any risk is minimised to be as low as 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:

• Legionella Risk assessment is undertaken every 2 years as mandatory.
• Water temperature is checked monthly and recorded on teamnet
• Shower head cleaned monthly and recorded by cleaning staff.
• Immunisation; As a practice we ensure that all our staff are up to date with their hepatitis vaccinations and are referred to occupational health for additional vaccinations they may require, as applicable to their role, for example MMR and flu vaccinations.
• Curtains; The NHS Cleaning specifications state that curtains should be checked regularly, and fabric curtains cleaned every 6 months. If disposable the curtains should be changed if visibly soiled, and every 12 months. Clinical staff are aware that minimal handling of curtains is recommended and should be done so after removal of examination gloves.
• The vertical window blinds are seen as low risk and therefore do not require a particular cleaning regime other than regular vacuuming to prevent dust build up.
• Hand washing sinks are in each clinical room.

Training

• All staff and contractors receive IPC induction training on commencing their post, this is provided by i-learn. Thereafter, all staff receive refresher training annually.
• IPC lead attends the quarterly IPC lead nurse Network meetings as able. Notes from this meeting are forwarded should attendance not be possible. All relevant information is circulated and polices/protocols updated as needed.

          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:

• All IPC related policies are in date for this year.
• Policies relating to infection prevention and control are available to all staff on teamnet, and are reviewed and updated annually, or amended on an ongoing basis as per current advice and guidance.

          Responsibility

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

          Review

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

This annual statement will be updated on or before May 2027.

Signed by

N.Bere

For and on behalf of Bramblehaies Surgery