Infection Prevention & Control Statement




We aim to keep our surgery clean and tidy and offer a safe environment to our patients and staff. We are proud of our modern, purpose built Practice and endeavour to keep it clean and well maintained at all times.

If you have any concerns about cleanliness or infection control, please report these to our Reception staff.

image depicting infection control

Our GPs and nursing staff follow our Infection Control Policy to ensure the care we deliver and the equipment we use is safe.

We take additional measures to ensure we maintain the highest standards:

  • Encourage staff and patients to raise any issues or report any incidents relating to cleanliness and infection control.  We can discuss these and identify improvements we can make to avoid any future problems.
  • Carry out an annual infection control audit to make sure our infection control procedures are working.
  • Provide annual staff updates and training on cleanliness and infection control
  • Review our policies and procedures to make sure they are adequate and meet national guidance.
  • Maintain the premises and equipment to a high standard within the available financial resources and ensure that all reasonable steps are taken to reduce or remove all infection risk.
  • Use washable or disposable materials for items such as couch rolls, modesty curtains, floor coverings, towels etc, and ensure that these are laundered, cleaned or changed frequently to minimise risk of infection.
  • Make Alcohol Hand Rub Gel available throughout the building

Infection control annual statement

Purpose of the statement

In line with the Department of Health, The Health and Social Care Act 2008: Code of Practice on Prevention and Control of Infection and its Related Guidance (2015), the practice annual statement will be generated each year. It will summarise:

  • Any infection transmission incidents and any action taken (these will have been reported in accordance with our Significant Events Report procedures).
  • Details of any infection control audits undertaken and actions taken.
  • Details of any infection control risk assessments undertaken.
  • Details of any staff training.
  • Any review and update of policies, procedures and guidelines.
  • Health and Social Care Act 2008
  • Practice infection control lead – Edna Manyusa is responsible for annual and monthly of infection control audit.
  • In 2017 no significant events have occurred at the practice relating to infection control, e.g., needlestick injuries, vaccine refrigerator breakdown. No outbreak of an infection such as any multiple cases of diarrhoea and vomiting, norovirus, or clostridium difficile.
  • Risk assessments and audits related to infection control are carried out monthly and an aggregation on an annual basis.
  • All clinical and non-clinical staff (including the cleaner) undertakes infection control training on a 3 yearly basis. Our current education provider is Blue stream academy.
  • Lead for the prevention and Control of Infection
  • Significant events
  • Audits and risk assessments
  • Staff training
  • Policies, procedures and guidelines: All infection control policies are reviewed and updated annually. This is on-going and amendments will be made as current advice changes.

Infection Control Statement - August 2021

Annual Statement for Infection Prevention and Control (Primary Care)

It is a requirement of The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance that the Infection Prevention and Control Lead produces an annual statement with regard to compliance with good practice on infection prevention and control and makes it available for anyone who wishes to see it, including patients and regulatory authorities.



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. It summarises:

  • 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 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 Pembridge Villas Surgery Lead for Infection Control: Edna Manyusa.  

The IPC Lead is supported by: Alesandra Iglesias

The Infection Control Lead attends annual training needs and regular Infection Control updates.

Infection transmission incidents (Significant Events)

  • Repairing faulty tap in clinical room

Infection Prevention Audit and Actions

The Annual Infection Prevention and Control audit was completed by Edna Manyusa

As a result of the audit, the following things have been changed in Pembridge Villas Surgery:

  • Toys and magazines removed from waiting area
  • Telephone triage before entry to surgery
  • Staggered appointments
  • Minimal amount of people in waiting area
  • Screening patients before entry
  • Social distancing/barriers between patients and reception staff.
  • Twice weekly Covid staff testing
  • Daily cleaning room charts. checklist
  • Cleaning of clinical rooms and equipment after each patient encounter
  • Social distancing between staff
  • Some staff working from home

The following things are future changes on the agenda to be updated:

  • Continue to follow government rule
  • Maintain clinical rooms cleaning schedules
  • Continue to promote vaccinations for staff and patients

An audit on Minor Surgery was undertaken by:

Simon Ramsden

The outcome revealed no infections.

As a result of the audit, no changes to be made.

An audit on clinical rooms and infection control identified rooms that required decluttering and PPE requirements.

The Pembridge Villas surgery plan to undertake the following audits during 2021/2022.

  • Antibiotic use
  • Clinical room audits
  • Hand washing
  • PPE donning and doffing among staff

Risk Assessments

Risk assessments are carried out so that best practice can be established and then followed. In the last year the following risk assessments were carried out / reviewed:

Legionella (Water) Risk Assessment:

  • Immunisation: As a practice we ensure that all of our staff are up to date with their Hepatitis B immunisations and offered any occupational health vaccinations applicable to their role (i.e. MMR, Seasonal Flu, Covid).
  • Curtains: The NHS Cleaning Specifications state the curtains should be cleaned or if using disposable curtains, replaced every 6 months. To this effect we use disposable curtains and ensure that all clinical areas (treatment rooms/minor ops) are changed every 6 months. All curtains are regularly reviewed and changed if visibly soiled.

We have a cleaning specification and frequency policy for staff and cleaners


  • All our staff receives mandatory training in infection prevention and control.
  • The Infection Control Lead attends annual training needs and regular Infection Control updates.
  • GPs have undertaken specialist training in Minor surgery, infection prevention and control.


The following policies are currently being updated:

  • Policies relating to Infection Control are available to all staff and are reviewed and updated annually and all are amended accordingly as current advice, guidance and legislation changes. Infection Control policies are circulated amongst staff for reading and discussed at meetings.


It is the responsibility of each individual to be familiar with this Statement and their roles and responsibilities under this.

Review date

  • September 2022

Responsibility for Review

The Infection Prevention and Control Lead and Practice Manager are responsible for reviewing and producing the Annual Statement.