IPC Annual Statement

Gudge Heath Lane Surgery

IPC Annual Statement

Completing the 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.

As best practice, the Annual Statement should be published on the Practice website.

The Annual Statement should provide a short review of any:

  • known infection transmission event and actions arising from this;
  • audits undertaken and subsequent actions;
  • risk assessments undertaken for prevention and control of infection;
  • training received by staff; and
  • review and update of policies, procedures and guidance.


Below is a suggested template for the Annual Statement compiled from national guidance and examples of best practice found on the internet. Practices can (and should) adapt the template and add further detail/headings/examples but the five key headings (above) must be included. If the practice are unable to complete one or more of the five key headings, it is likely that the practice are not compliant with the health and Social Care Act.













Infection Control Annual Statement


This annual statement will be generated each year in January 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

Gudge Heath Lane Surgery Infection Prevention and Control Lead:: Cheryl Mair (CM), Practice Manager.  This will be updated once we have a nurse in post to share the lead role.  In the interim Cheryl will liaise with the GP Partners.

CM attended an IPC Lead update in 2023 and have kept updated on infection prevention practice.

Infection transmission incidents (Significant Events)

Significant events (which may involve examples of good practice as well as challenging 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 Education Meetings and learning is cascaded to all relevant staff.

As a result of these events, Gudge Heath Lane Surgery has:

  • Continued with an annual infection control update for both clinical and non-clinical staff
  • Ensured Infection Control Guidance remains accessible to all staff.

Infection Prevention Audit and Actions

The Annual Infection Prevention and Control audit was completed by CM in January 2023.

As a result of the audit, the following things have been changed:

  • Cleaning audits to be carried out by cleaning company and audits provided to CM by email
  • Room cleaning audits to be carried out by room user and provided to CM at the end of each month

The Practice plan to undertake the following audits in 2024:

  • Annual Infection Prevention and Control audit
  • Hand hygiene audit

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: The practice has conducted/reviewed its water safety risk assessment to ensure that the water supply does not pose a risk to patients, visitors or staff.

Immunisation: As a practice we ensure that all of our staff are up to date with their Hepatitis B (Clinicians) and MMR immunisations 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.

Curtains: Disposable curtains are used in clinical rooms and are assessed at least annually.  All curtains are changed if damaged or soiled.

PPE: Appropriate PPE is available to all Staff and guidance adhered to in the wearing of PPE.  Areas are cleaned and decontaminated according to up to date COVID guidance.


All our staff receive annual training in infection prevention and control.

Infection Control Leads have an annual update.  Information is then disseminated to the clinical team within the monthly Education Meeting, and the non-clinical staff via annual e-learning.

CM attends the Infection Control Leads Forum led by HIOW ICB.   This has been operating remotely since the COVID period.

The IPC Leads complete an annual e-learning update on all areas relating to IPC.


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 annually, and all are amended on an on-going basis as current advice, guidance and legislation changes. Infection Control policies are circulated amongst staff for reading and discussed at meetings on an annual basis.


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

Review date

January 2025

Responsibility for Review

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

Cheryl Mair (Practice Manager):   C. Mair

For and on behalf of Gudge Heath Lane Surgery