IPC Annual Statement



                              Infection Control Statement

                             Author Andrea Parkin November 2023

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 regarding Compliance with good practice on infection prevention and control.


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 any staff training.

Any review and update of policies, procedures, and guidelines.

Infection Transmission Incidents (Significant Events)

There have been no significant events relating to infection prevention and control across the organisation in 2022.This statement provides an overview of the key systems and processes, across the organisation to provide assurances that Infection Prevention and Control standards are high, across our organisation.

Guidance regarding the standards of cleanliness, as below:


This replaces the 2007 specifications for NHS cleanliness. This guidance mirrors expectations for GP providers which are covered by our regulations and the code of practice. For example, IPC audit processes, waste management, cleaning schedules and maintenance of equipment.

To date from the CQC website latest position statement is that -There are no expectations that CQC require star ratings or logos to be displayed in general practices. CQC continue to regulate using Regulations 12 and 15 and will also regulate using the code of practice on prevention and control of infection.

Following the introduction of our own BHF cleaning company we have reviewed the needs of our services and delivery of high cleaning standards and the IPC lead alongside the cleaning manager have benchmarked our cleaning and IPC managerial support to be of a high standard. We have sought to improve this further and have consulted with the IPC leads at BHNFT and have started training so that the cleaning manager and team can start to assess and map rooms being cleaned for functional risk. Cleaning frequency of a given item is determined by the Functional Risk (FR) of the room it is in. It makes sense that an armchair in a high-risk area such as a Minor surgery room, needs to be cleaned more frequently than a chair in an admin office. There are six FR categories, with FR1 being the highest risk and FR6 the lowest. This work is beginning and will be focused on as part of 2024 IPC review across the organisation and the key areas where we provide services. Owning our building comes with other potential areas of IPC risk due to high levels of visitors and users, which will be reviewed quarterly, by the Head of IPC, Head of cleaning services, alongside the Priory building manager and other EMT members.

Risks Identified

Whilst COVID cases continue to occur BHF continues its vaccination delivery program through the Winter and other seasons to those identified as vulnerable. Other risks emerge and risks identified recently are the outbreaks of Measles locally in South Yorkshire. This is attributed to the reduction in the uptake of MMR vaccine. Risks and diseases are closely monitored, and information cascaded to staff groups. At least 95% of children should be double vaccinated by the age of five. But the UK is well below that target. Latest figures show only 84.5% had received a second shot of the protective measles, mumps and rubella (MMR) jab - the lowest level since 2010-11. Measles can make children extremely sick. The main symptoms are a fever and a rash, but it can cause serious complications including meningitis. Staff are aware that those identified as Measles cases should be isolated and PPE used and to contact the IPC team.

System support The Head of IPC and Nursing sits on the out of hospital team meetings, which are weekly meetings supporting system wide responses, to any challenges, which includes Infection prevention and control outbreaks and any new pandemic response with system colleagues across the Health and Social Care in Barnsley. Services have returned to near normal, and we are following the National NHSE updates for Covid Infection control and our local Infection Control Teams specialist guidance’s to ensure the population who use our services are kept safe.


Staff providing care.

·         show their understanding by applying the infection prevention and control principles in this guidance.

·         maintain competence, skills and knowledge in infection prevention and control by attending education events and/or completing training.

·         communicate the infection prevention and control practices to be conducted by colleagues, those being cared for, relatives and visitors, without breaching confidentiality.

·         have up-to-date occupational immunisations, health checks and clearance requirements as appropriate.

·         report to line managers, document and action any deficits in knowledge, resources, equipment and facilities or incidents that may result in transmitting infection including near misses, e.g., PPE failures.

·         not provide care while at risk of transmitting infectious agents to others; if in doubt, they must consult their line manager, occupational health department, and or their infection prevention and control lead.

·         inform the IPC Lead and local UKHSA health protection team of any outbreaks or serious incident relating to an outbreak in a timely manner.

 Identification of Incidents

There is a culture that promotes incident reporting, including near misses, while focusing on improvement of services.

·Infection Control Link leads at each site will identify any issues via quarterly IPC audits and any actions will be taken accordingly.

·Infection Control specialist nurses from the BHNFT commissioned service will audit and inspect sites annually, these are sent to the IPC leads and reports will be reviewed, and actions followed annually, by the IPC lead for the organisation.

·Infection control guidance remains accessible to all staff via folders across the sites. BEST Website and the commissioned services IPC monthly training updates.

·Systems are evident at each site with file and folders with organisational information.

·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 Clinical Governance Meeting which is cascaded to all relevant staff.

Infection Prevention Actions

The iHeart365 clinical lead is responsible for Infection control audit alongside the Operational Manager for iheart365.

Nurse Associates at each GP practice will now conduct the peer audit systems.

Infection control information is regularly updated following the pandemic as new and updated guidance becomes available from NHSE and is reviewed by the Head of Nursing.

Regular Audit

The Organisation plans to undertake the following audits in 2024:

·Annual External Infection Prevention and Control audit.

External audits every January are available, are conducted by the specialist IPC team across the practice sites and iheart365. The actions from these audits have been reviewed and there are actions for estates, and our cleaning services from the quarterly audits. I heart365 has now changed location to Priory Centre, with two extended and OOHs sites operational at Woodland Drive and Chapelfield GP centres.


There is close liaison with the teams and IPC Head of Nursing for any support required. The audits are also reviewed with the managers by Head of Nursing and any challenges discussed. All our BHF sites and external partners score very highly at 98% or above this year in our external audits. This assurance is welcome as demonstrates we keep our population safe.


·Quarterly Environment, Decontamination and Sharps Audits These audits continue. No sharps Injury reports from any of our sites this year.

·Waste Management Audits - These audits are mandatory and must be completed as part of your Duty of Care under Section 34 of the Environmental Protection Act 1990. Anenta are the current provider that we send audits to. The Primary care manager carries these out alongside the Head of Nursing.

·Minor Surgery Outcomes Audit.

 Medical colleagues undertaking minor surgery post pandemic are asked to re start audits, review their audits and communicate audits to the IPC lead moving forward.


Our audits are available to view, these are saved on our shared drive with our policies. Audits are followed up by the IPC Lead who is the Head of Nursing to note any actions required, from staff across the organisation.

Risk Assessment

Risk assessments are conducted so that best practice can be established and followed.

In the last year, the following risk assessments were conducted:

·Legionella (Water) Risk Assessments

The organisation estates service reviews water safety risk assessment to ensure that the water supply does not pose a risk to patients, visitors or staff.


As an organisation we have occupational health advice and support from BHNFT occupational health services via NHSE contracting. The organisation with occupational health risk assesses and audit to ensure all our staff are up to date with their Hepatitis B immunisations and offered any occupational health vaccinations applicable to their role (i.e., MMR, Seasonal Flu).

·We take part in National Immunisation campaigns for patients and offer vaccinations in house and via home visits to our patient population.

·Disposable curtains are used in clinical rooms across the organisation and are changed regularly six monthly and if soiled according to the practice /BHNFT instruction.

·All curtains are changed six monthly and changed more frequently if damaged or soiled.

·Social distancing review if needed.

·PPE review.

·Face covering wearing.

·Outbreak management (please see outbreak management plan).

·Pausing of spirometry due to IPC concerns, this is currently being reviewed by a ICB working group for Barnsley.


All our link staff receive annual training in infection prevention and control, specifically for link staff. Clinical staff either attend an annual Infection Control Update or complete an e-learning update. Training is logged via e-learning platforms and certificates in HR files.

Link for IPC Update training

IPC leads and deputies at sites are invited to specialist IPC link training held regularly by the commissioned IPC team BHNFT.


Following review of the policies BHF have adopted Harrogate IPC specialist polices for general practice, across the organisation.

These have been added to HR System and Shared Drive.

Review Date

November 2024 or sooner if any changes to process, commissioning, or legislation changes.

Responsibility for Review

The Infection Prevention and Control Lead, for Barnsley Healthcare Federation is the Head of Nursing, who is responsible for reviewing and producing the Annual Statement.


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