Infection Control Statement

Annual IPC Statement 2022-2023

Date April 2022 – March 2023


This annual Infection Prevention Control (IPC) statement will be generated each year in the month of 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 or transmission incidents and any action taken (these will have been reported in accordance with our ‘Learning Event’ procedures).
  • 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) Lead

The lead for infection prevention and control at St Luke’s Surgery is Chloe Jones, Practice Nurse, however, is being handed over to Suzanne Green Lead Practice Nurse from April 2023

The IPC Lead is supported by Dr Elizabeth Charlwood

Infection transmission incidents (Significant Events)

Significant events involve both examples of ‘good’ and ‘poor’ practice.

All significant events are discussed at one of our regular clinical practice meetings attended by GPs and Practice Nurses. For each that may occur, a specific form is completed, reflected upon and discussed at one of these regular meetings, so that areas of learning and improvement can be identified.

In the past year there have been ‘zero’ learning events raised that have related to infection control. There have also been ‘zero’ complaints regarding cleanlines.

Infection prevention audit and actions

Infection Prevention Society Audit Toll was completed 17th January 2023 and resulted in the following actions:

  • The implementation of new waste disposal bags for infectious waste – referred to as ‘Tiger bags’ due to their yellow and black stripey appearance.
  • Updated ‘Hand Washing’ posters.
  • All staff have undergone annual infection prevention training including a hand-washing assessment and spills kit training (this explains correct procedure for dealing and cleaning surfaces/equipment as a result of there being any vomit/faeces/blood spills within the surgery.
  • Updated ‘needle stick and sharps injury’ protocol.
  • Review of how the communal blood pressure machine is cleaned after each patient use.

Risk Assessments

Risk assessments are carried out so that any risk is minimised to be as low as reasonably practicable. Additionally, a risk assessment which can identify best practice can be established and then followed.

In the last year the following risk assessments were carried out/reviewed:

  • Appropriate closing of Sharps Bins
  • Covid- 19 – measures taken to protect staff and patients
  • Flu ‘Drive through’ day at the Guildford Cathedral site
  • Changing Clinical Waste Sacks. Due to changes directed by our Clinical waste disposal company ‘Anenta’ the bags within clinical rooms have changed as follows:

All GP rooms and HCA rooms have changed from using an ‘orange clinical waste’ bag to that of a ‘Tiger’ yellow and black striped bag to contain all clinical waste now referred to as ‘offensive waste’.

The PN rooms and the ‘minor operation’ treatment room will remain having ‘orange clinical waste’ bags which will contain all the following ‘clinical waste’ including ‘infectious clinical waste’ and also ‘offensive waste’.

  • Staff vaccination records and New joiners

In the next year (2023-2024) the following risk assessment will also be reviewed:

  • Curtain changes surrounding the clinical couches every 6 months
  • General IPC updates
  • Protocol for the daily cleaning of all clinical equipment, surfaces and door handles in all clinical rooms


St Luke’s staff on appointment receive IPC induction training and all the staff receive refresher training annually, the level of which, is dependent on the staff members role and responsibilities.

  • All Staff receive annual training on IPC
  • All clinical and non-clinical staff have completed IPC e-learning modules
  • The IPC lead attends primary care infection control forum and cascades information throughout the team

Policies and procedures

The IPC related policies and procedures which have been written, updated or reviewed in the last year include, but are not limited, to:

  • Infection Prevention Control Policy
  • Needle Stick/ Sharps injuries policy
  • Clinical waste Management Policy

Additionally, all policies are amended on an ongoing basis as per current advice, guidance, and legislation changes.


As a team at St Luke’s Surgery, Infection Prevention Control is regarded as highly important and we as a practice maintain high standards for infection prevention control. It is the responsibility of all staff members at St Luke’s Surgery to be familiar with this statement and their roles and responsibilities under it.


The IPC lead is responsible for reviewing and producing the annual statement

This annual statement will be updated on or before April 2024.

S Green
Lead Practice Nurse
April 2023