Somerton House Surgery
Infection Control Annual Statement
2015-16
Purpose
This annual statement will be generated each year. It will summarise:
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Any infection transmission incidents and any action taken (these will have been recorded in
accordance with our Significant Event procedure)
Details of any infection control audits undertaken and actions taken.
Details of any infection control risk assessments undertaken.
Details of staff training.
Any review and update of policies, procedures and guidelines
Background
Somerton House has one lead for infection, prevention control.
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Alison Francis – Practice nurse
Significant Events
In the past year there have been no significant events raised that related to infection control.
Audits
An audit on minor surgery procedures and post-operative wound infection was undertaken in December
2015 by Sister Edwards. No infections were reported.
A hand hygiene audit was performed by Alison Francis in May 2015 with a light box to identify poor or
incorrect hand washing. This highlighted the importance of hand washing for all staff involved in patient
care and the recommended method and procedure to follow when washing hands.
Risk Assessments
Alison Francis used an audit tool for a full clinical infection control inspection.
This included:
Hand hygiene 100% compliancy achieved.
Clinical practice including specimen handling and equipment use with 100% compliancy achieved.
Developed 2011 – CS – Reviewed – CS 2013 – Reviewed – TE/CTT 2014
Reviewed and updated TE – December 2015
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Sharps handling and disposal with 92.3% compliancy achieved. Point of action from this is to ensure the
sharp boxes are all labelled with source from which they came.
Waste disposal with 85.7% compliancy achieved. Points of action identified were cleaning of outside
storage waste bin and labelling of bags to identify source from which they came.
Decontamination of equipment 100% compliancy achieved.
Environment including checking of cleanliness with 100% compliancy achieved.
Cleaning products 100% compliancy achieved.
Specimen handling 100% compliancy achieved.
Vaccine transport and storage with 89.4% compliancy achieved. Points of action identified were not to
store items on the top of the fridge and not to use the bottom drawer of the vaccine fridge for vaccine
storage.
Staff Training
Sister Francis last gave a hand hygiene talk in May 2015 and an update given on all areas of infection
control as identified in the latest audit. Sister Francis and Sister Edwards will provide infection, prevention
and control induction training to all new members of staff.
Infection control courses are completed on-line by staff and are as follows:
Cleaner: Cleaning and Infection Control, October 2012
Sister Edwards: On-line, Infection Control, December 2014
Sister Francis: On-line, Infection Control, November 2012, but continues to attend regular quarterly meetings and
will feedback any legislative changes.
Policies, Procedures, Guidelines
Most policies are formally reviewed annually, however all are amended on an ongoing basis as current
advice changes, or need arises.
Developed:Employees’ Factsheet: Infection Control – July 2012
National Specification for cleanliness in the NHS – August 2010
Cleaning duties – September 2012
Safe Management of Healthcare waste – March 2011 & December 2015
Sickness absence policy – including contact with infectious diseases – Sept 12
Disposable instrument use and disposal – Sept 2012
Developed 2011 – CS – Reviewed – CS 2013 – Reviewed – TE/CTT 2014
Reviewed and updated TE – December 2015
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Policy for protection of staff against Hep B – Sept 2012
Disposal of Sharps – Nov 12
Needle stick Injury – Aug 12
Isolation of patients – Nov 12
Toy cleaning procedure – Nov 12
Medicines management Policy – Oct 13
Infection control – biological substances – Nov 12
Procedures following sharps injury and contamination July 2014
Procedure for Ear Irrigation – April 2014.
Audits undertaken 2015
Hand Hygiene Facility Audit and Infection Control Audit – Sister Edwards December 2015
Hand Hygiene staff audit of hand washing technique using a light box – May 2015
Self-Assessment Audits for Hand Hygiene, Clinical Practice, Sharps Handling and Disposal, Waste Disposal,
Decontamination of Equipment, Environment, Cleaning Products, Specimen Handling, Vaccine transport and Storage
by Sister Francis November 2015 with an overall 100% success rate.
Developed 2011 – CS – Reviewed – CS 2013 – Reviewed – TE/CTT 2014
Reviewed and updated TE – December 2015
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