Infection Prevention and Control Policy


Infection Control Annual Statement


An 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

Lead for Infection Prevention and Control within South Downs Health and Care LTD: Dr Miriam Malak – Clinical Director and Sandra Punchard (acting) nurse lead

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 and learning is cascaded to all relevant staff.

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

Infection Prevention Audit and Actions

Regular audit and checks are undertaken and actions plans in place. Premises have been redecorated and new cleaning schedules introduced.

Hand wash appliances have been audited throughout the surgery with with new wall mounted dispensers for soap and alcohol gel implemented. SDHC have added wall mounted glove and apron holders.  
Monthly IPC audits of premises have commenced in March 2023, this will be undertaken by a member of the admin team following direction from SP. Any concerns to be reported to MM or SP. SDHC use Safe management of the care environment Audit Tool for General Practice - Infection Prevention Control audit template.

SDHC plan to undertake the following audits in 2023:

Monthly IPC audits of the premises

Annual audit of IPC including leadership

A domestic cleaning review is to be undertaken by IPC lead in consultation with Consult cleaning services. A deep clean was undertaken in Sept 2023.

Annual hand hygiene audit of all clinical staff is undertaken. SDHC will use Hand hygiene Audit Tool for General Practice - Infection Prevention Control audit template.

Risk Assessments

Risk assessments are carried out so that best practice can be established and then followed. In the last year April 2023 – March 2024 the following risk assessments were carried out / reviewed:

Legionella (Water) Risk Assessment: SDHC has conducted/reviewed its water safety risk assessment to ensure that the water supply does not pose a risk to patients, visitors or staff. External assessment is carried out monthly by NHS property services, staff also run taps twice weekly in all areas with sinks and record on the water log and on the admin booking form.

Immunisation: As a company SDHC ensure that all of our staff are offered any occupational health vaccinations applicable to their role (i.e. Hep B, MMR, Coronavirus, Seasonal Flu) following risk assessment according to role. This is monitored by HR.

PPE: Staff and patients are supplied with face masks to wear (non-mandatory) when dealing with patients within our clinical services following a local risk assessment. Patients are encouraged to use hand gel on entry to the building. SDHC will review this guidance and risk assessment annually or sooner if national guidance requires.

SDHC deliver Coronavirus and Influenza National Immunisation campaigns for patients who are in care homes and who are housebound and offer covid vaccinations in house to our patient population. A phlebotomy and sexual health clinic is also offered.

Cleaning specifications, frequencies and cleanliness: SDHC also have a cleaning specification and frequency policy which our cleaners and staff work to. An assessment of cleanliness is conducted by the cleaning team and IPC lead as an ongoing assessment, at monthly audit checks and annual audit.

Hand washing sinks: The premises have clinical hand washing sinks in every room for staff to use. All liquid soap dispensers and alcohol gel dispensers have been replaced throughout SDHC premises.

SDHC have no patient curtains in rooms or toys in the waiting room. No minor surgery is undertaken at SDHC.


All clinical staff receive mandatory training in infection prevention and control (level 2).

Non-clinical staff receive mandatory training in infection prevention and control (level 1).

The IPC lead attends quarterly IPC Lead Nurse forums organized by the Infection and Prevention Team NHS Sussex. Relevant information is disseminated to staff and procedures updated as required.


All Infection Prevention and Control related policies are regularly updated, staff can always access the most up to date copy on Digitalis

Policies relating to Infection Prevention and Control are available to all staff on the staff Digitalis platform they are shared with all new staff. The policies are reviewed and updated annually and all are amended as required if current advice, guidance and legislation changes. Updated Infection Prevention and Control policies will be circulated amongst staff when finalised.


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

Review date

March 2024

Responsibility for Review

The Infection Prevention and Control Lead is responsible for reviewing and producing the Annual Statement

Kirstie Ingram, Director of Quality Compliance and Engagement

Dr Miriam Malak, Clinical Director