Infection Control Policy


We aim to keep our surgery clean and tidy and offer a safe environment to our patients and staff and endeavour to keep it clean and well maintained at all times. 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 measures to ensure we maintain the highest standards for infection prevention and control:

  • 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.

This annual statement will be generated each year in April 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) Team

  • The Professional Lead for Infection Prevention and Control at South Norwood Hill Medical centre is Margaret Bell, Nurse Practitioner.
  • The IPC link Person is Dr Ide OJO, Managing Partner.

Infection transmission incidents (significant events):

Significant events are investigated in detail to see what can be learnt and to indicate changes that might lead to future improvements. All significant events are reviewed in the monthly or weekly meetings and learning is cascaded to all relevant staff.

In the past year there have been no significant events raised that related to infection control.

  • 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 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 have been no significant events raised that related to infection control. There have also been no complaints made regarding cleanliness or infection control.

Infection prevention audit and actions

The Infection Prevention and Control internal audit was last completed by Margaret Bell on the 6th April 2021, this is done quarterly, and the ooutcomes of the Audits are recorded on a template document stored on the practice Shared Drive and they are discussed at the Practice meeting.

The CQC inspection report in July 2021 indicated the minor operation room needs a new floor. This has been completed and a new floor was installed in September 2021.

All the sinks in the clinical and treatment rooms have been changed to the sinks that meet IPC criteria.

The treatments rooms, consulting rooms and minor operating theatre have been refurbished.

Minor Surgery Audit

This was carried out by Dr. J Ojo. No infections were reported in all the minor surgery undertaken by Dr. Ojo. An audit was also carried out on the histology results received. No Actions where recommended from this audit.  Dr. Ojo attend mandatory updates for Minor surgery on a regular basis.

Infection Control Audits

Audits are carried out on a monthly basis. As a result of the audit and continuous infection control observations internally the following things have been changed in the practice:

  • Hand washing E Learning to be completed by all staff annually.
  • All new member of staff to have Infection control as part of their induction
  • Signage in Patient Toilet has been replaced, with regard to changing Table and cleaning of this.
  • Hand towel dispensing unit planned replacement as current ones are not able to be opened to place hand towels in dispenser.
  • All consultation rooms are now fitted with disposable curtains around beds.
  • Introduction of safety needles for injections and for vacutainers therefore reducing the risk of Needle stick injuries as per The Health and Safety “Sharp instruments in Health care” Regulation 2013.

Future/Ongoing Audits to be planned

SNHMC Plan to undertake the following audits in 2021/2022

  • Infection Prevention and Control audit – Quarterly
  • Minor Surgery outcomes audit by Dr Ojo responsible Clinician Annually
  • Environmental audit – Monthly or at least Bi-monthly
  • Hand hygiene E Learning Audit Annually
  • Introduction of a Phlebotomy Audit Annually
  • Vaccine Management/Cold chain Audit Annually
  • Vaccine Management Review Quarterly
  • Sharps Bin Audit Quarterly

Risk Assessments and Outcome and action taken

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.

Risk Assessments were carried out in the following Areas

  • Sharps bins – currently all are wall mounted and are changed every 3 months regardless of quantity of sharps.  All sharps’ bins were labelled and correctly assembled. One clinic call room that had no wall fixing was identified and the sharp bin was correctly wall mounted.
  • Legionella (Water) Risk Assessment: The practice performs a water safety risk assessment to ensure that the water supply does not pose a risk to patients, visitors or staff. The water has been graded as safe. This is undertaken by an accredited independent legionella testing agency.
  • Immunisation: As a practice we ensure that all of our staff are up to date with their Hepatitis B immunisations at time of interview by Practice Manager, after a risk assessment looking at their clinical role and offered any occupational health vaccinations applicable to their role. We take part in the National Immunisation campaigns for patients and offer vaccinations in house and via home visits to our patient population.
  • Waste bins in Clinical areas and Non-Clinical areas – All clinical rooms have a designated Orange bag Waste bin and non-waste bin. Pedals of bins that were broken but action of pedal not affected. Action: All damage bins are now replaced with functioning pedaled operated
  • Influenza vaccination of staff – this year we promoted Influenza vaccination for all staff. Each member of staff received a document outlining the benefits to patients and themselves. This form returned consenting or declining vaccination. The 2019/2020 uptake of vaccination was 88%.
  • Curtains: All the curtains are now disposable and will be replaced every 6 months.
  • Hand washing sinks: The practice has clinical hand washing sinks in every room for staff to use. In 2021 the surgery has undertaken major building works to refit all clinical rooms with sinks and taps to meet current recommended standards.
  • Clinical rooms: All clinical rooms have now been fitted with new cupboards, work surfaces, curved flooring and Wall mouldings to meet current recommended standards for Infection control.

In the next year, the following risk assessment will also be reviewed:

  • Cleaning standards
  • Handwashing
  • Staff Immunisation Audit
  • Sharps bin Audit
  • Clinical waste Audit
  • Staff immunisation Audit

Infection Control Training

  • Due to Covid19 pandemic Training of staff in Infection control has not been able to occur in Staff meetings which are currently suspended due Covid19 guidance. The Infection Control Lead has reminded Staff on an opportunistic/individual occurrence regarding Infection Control measures.
  • The Link person and IPC Lead are fully trained an accredited for IPC.
  • Blue Stream eLearning will be undertaken annually by all staff, and a face to face hand washing audit will take place at regular intervals, at least annually.  Audit of the clinical waste disposal at regular intervals.
  • Staff involved in risk assessments at South Norwood Hill Medical centre, all staff and contractors receive IPC training.
  • IPC training through eLearning is included in the mandatory training for staff on commencing their post.
  • All staff to receive refresher IPC training annually.

IPC training in the previous year have been delivered through staff meetings, e-Learning and face to face teaching.

Covid19 Vaccination Programme

All clinical and non-clinical staff have been offered Covid19 vaccinations in line with Public Health England guidance.

Lateral Flow Testing

Surgery Staff are self-testing at home twice weekly and all results are logged. Staff also need to report to Government Covid19 Results website.  Appropriate action to be taken if a positive result occurs.   Practice manager will follow recommended guidance if this occurs with a member of staff.

External Infection Control AUDIT

An external IPC audit took place on 7th February 2022 by Infection Control solutions.  Actions from this audit included:

  • To ensure clinical waste disposal guidance are followed and include this in the IPC audits.
  • To have a separate cleaning room for cleaning equipment.
  • Install a fly catcher on the minor operation theatre window.
  • Reduce the number of posters on the practice wall and notice boards.
  • To undertake annual Face to Face handwashing Audit.
  • Clinicians to sign undertaking for cleaning patient equipment after clinical use.

Policies and procedures

The infection prevention and control related policies and procedures that have been written, updated or reviewed in the last year including:

  • Infection Prevention Control Policy
  • Safe Water Policy (Legionella)
  • Waste disposal Policy
  • COSHH Risk Assessment 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 South Norwood Hill Medical Centre to be familiar with this statement and their roles and responsibilities under it.


  • The IPC Lead is responsible for reviewing and producing the annual IPC statement.

Signed by Dr James OJO
Lead GP and Senior Partner
For and on behalf of South Norwood Hill Medical Centre.