Infection Control Policy


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. It summarises:

  • Any infection transmission incidents and any action taken (these will have been reported in accordance with our Significant Event procedure / Notifiable diseases)
  • 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

South Norwood Hill Medical Centre Infection Prevention and Control Lead is Margaret Bell, Practice Nurse. M Bell has completed an Infection prevention and Control course and keeps updated on Infection Control Practices

This role is supported by the Infection Prevention and Control link which is Dr Ide Ojo, Manager Partner. Dr Ide Ojo has completed a relevant Infection control course and keeps updated on Infection control Practices.

The Infection Control Lead will carry out the following within the practice:

  • Increase awareness of Infection Control issues amongst staff and clients
  • Help motivate colleagues to improve practice
  • Improve local implementation of Infection Control policies
  • Ensure that practice-based Infection Control audits are undertaken
  • Assist in the education of colleagues
  • Help identify any Infection Control problems within the practice and work to resolve these, where necessary in conjunction with the local Infection Control Team
  • Act as a role model within the practice
  • Disseminate key Infection Control messages to their colleagues within the practice

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.

There has been one event related to a Vaccine storage Incident with power interruption to the vaccine fridge. The Surgery followed Vaccine Incident guidance for UK Health Agency and an Informed Risk assessment completed, reporting of Incident to Screening and Immunisation team, Lead Pharmacist and assistance from Manufactures of all vaccines held in stock. Vaccines that where deemed as unstable where discarded and reported to Immform website.

Infection Prevention Audit and Actions

The Infection Prevention and Control internal audit was last completed by Margaret Bell on the January 2023, this is done quarterly.

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 were 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 to bi-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.
  • Hand Hygiene Audit, all members of Staff observed by M Bell IPC Lead, last completed August 2022.
  • All new member of staff to have Infection control as part of their induction
  • Hand sanitisers dispensing units installed in all consulting rooms, reception, corridors upstairs and downstairs.
  • Hand towel dispensing units replaced, 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.
  • All Clinical room cupboards fitted with sloping tops to the ceiling to meet current Infection control Best Practice requirements.
  • All clinical rooms and Minor ops. Room are fitted with the correct flooring to meet Best Practice recommended standards.
  • 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.
    The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013

Future/Ongoing Audits to be planned

SNHMC Plan to undertake the following audits in 2023/2024

  • 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
  • Vaccine Management/Cold chain Audit Annually
  • Vaccine Management Review Quarterly
  • Sharps Bin Audit Quarterly
  • Clinical and Non-Clinical waste bins Audit Quarterly
  • External Bin Audit for storage of bagged clinical waste before collection
  • Annual NHS England Infection Control Audit last completed September 2022.
  • Quarterly Infection control Audit

Risk Assessments and Outcome and action taken

Risks assessments are carried out to identify areas that can be improved so that the risk is minimised or be reduced to the lowest achievable level.

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. There has been no identified incidents
  • 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 undertaken by an accredited Legionella testing agency. On a monthly basis the Water temperature is measures and recorded. Dr Ide Ojo has undergone Approved training in Water management and Dr James Ojo is planning to undertake this training.
  • Immunisation: As a practice, we ensure that all of our staff are up to date with their Immunisations (including MMR). The Practice Manager reviews Hepatitis B immunisations at time of interview. 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.
  • Waste Management. Audit of the External bin to be included in the IPC audits to ensure Bin is locked at all times, Bags and securely tied and details of the Surgery Postcode are placed on each bag by the Cleaning Company.

Influenza vaccination of staff – We promoted this year Influenza vaccination for all staff. To encourage uptake was discussed at staff meeting regarding the importance of this. Each member of staff received a document outlining the benefits to patients and themselves. This form returned consenting or declining vaccination; the 2022/2023 uptake of vaccination was 65%.

Covid Vaccination Programme

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

Curtains: All the curtains are now disposable and will be replaced every 6 months. The last change took place in January 2023

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 Best Practice standards.

Clinical rooms: All clinical rooms have now been fitted with new cupboards reaching to the ceiling with sloped tops, worksurfaces, curved flooring and Wall mouldings to meet current recommended Best Practice standards for Infection control.

Infection Control Training

This has been delivered through Staff meetings, e-learning and on an opportunistic/individual occurrence regarding Infection Control measures.

IPC Lead and Link are trained by an accredited IPC organisation.

Blue stream eLearning will be undertaken Annually by all staff this is a Mandatory by all clinical and non-clinical staff. This Mandatory training includes Infection Control and Hand washing.

Lateral Flow Testing

Prior to 1st April 2023 clinical members of staff exhibiting Covid-19 symptoms were using Lateral flow test kits to determine status and to follow all follow UK Health Security Agency guidance for people with symptoms or who are testing Positive. All staff would then have to test negative on two consecutive days as part of a return-to-work policy.

As of 1st April 2023, this guidance has now changed. This guidance is as follows:

Healthcare staff whose job does not primarily involve providing direct inpatient care to severely immunosuppressed patients, who have symptoms of a respiratory infection, and who have a high temperature or do not feel well enough to go to work, are advised to stay at home and avoid contact with other people.

They are not required to take a COVID-19 test and should follow the guidance for people with symptoms of a respiratory infection including COVID-19. They should stay at home until they no longer have a high temperature (if they had one) or until they no longer feel unwell.

If these staff members have a positive COVID-19 test result, regardless of whether they have symptoms, they should follow guidance for the general public who have a positive test result.

Line managers should undertake a risk assessment before patient-facing healthcare staff return to work in line with normal return to work processes.

On returning to work, all staff members must continue to comply rigorously with all relevant infection control precautions, including appropriate personal protective equipment (PPE) use.

Local circumstances may lead to a decision to undertake symptomatic staff LFD testing in these settings, following risk assessment and direction from medical directors, nursing directors or infection prevention and control teams. In this situation, staff should follow local policy regarding criteria for returning to work.

Managing healthcare staff with symptoms of a respiratory infection or a positive COVID-19 test result – GOV.UK (

External Infection Control Audit

This was carried out on the 7th February 2022. The overall score for the surgery was 95% this was deemed as a high score and reflected South Norwood Hill Medical Centre commitment to ensure the highest standards of Infection control are attained.

Recommendations from this Audit where as follows:

  • Waste management. External Yellow Bin must be locked at all times. The bags must be securely tied and Surgery Postcode on each bag.

Action – Dr Ide Ojo to liaise with cleaning company to ensure this happens. Audit of this to be included in IPC inspection.

  • Installation of Fly catcher on Window of Minor Operations Room.

Action – This has now been installed.

  • Separate Room for Cleaning Equipment

Action – An are in garden has been identified as a site for purpose-built Unit to house cleaning equipment.

  • Clinicians to sign undertaking for cleaning patient equipment after each use

Action – Forms have been distributed by Dr Ide Ojo to each staff member to complete.

  • To undertake Annual Face to Face Handwashing Audit.

Action – The IPC lead or Link Person to be responsible for this Audit Annually.

All of the above recommendations and Action were completed in a timely manner over 2022.


All Infection Prevention and Control related policies are in date for this year.

Policies relating to Infection Prevention and Control are available to all staff and are reviewed and updated (as indicated by the review date), and all will be amended on an on-going basis as current advice, guidance and legislation changes have been made due to the ongoing Covid Pandemic.

Infection Control policies are uploaded to Shared Drive on computer system making them available to all staff and have been informed that they located there.

Polices reviewed Annually

  • Specimen Handling Protocol
  • Venepuncture Policy
  • PPE policy
  • Medical devices policy
  • Infection Control Policy reviewed
  • Cold chain Policy reviewed
  • Sharps Policy
  • Aseptic Technique Policy
  • Minor Operations Policy

Annual statement Review date

26th April 2023

Next Review date

April 2024

Responsible for Review

Margaret Bell Infection Prevention and Control lead.

Author of statement

Margaret Bell IPC lead on behalf of South Norwood Hill Medical Centre.