Annual Statement of Infection Control April 2023

Annual Statement of Infection Control updated April 2023




An annual statement is generated each year in April. The next annual Statement is due in April 2024.

The aim of this statement is to provide an update since last statement, which includes further evidence in the following topics:

  • Any infection transmission incidents and any action taken (these will have been reported in accordance with our Significant Events Reporting procedures).
  • Details of any infection control audits undertaken and actions taken.
  • Details of any infection control risk assessments undertaken.
  • Details of staff training.
  • Any review and update of policies, procedures and guidelines.



The infection prevention and control Clinical lead for Thistlemoor Medical Centre is

Dr Nalini Modha. The infection Control Nurses lead is Nadia Batul can be contacted for general queries for nurses.

The Administrative leads are Roszia Bi, Rachana Khatri, Paulina Piatkowska and Monika Klosowicz.

Significant events

There have been no significant events raised that are related to infection control since the annual statement.

Significant events documentation is kept and reviewed by Paulina Janczura.

All significant events documentation is reviewed and discussed in clinical meetings and Practice Meetings with all staff regularly.


The main team responsible for completing the audits is Monika Klosowicz and Paulina Piatkowska supported by Roszia Bi and Rachana Khatri.

The purpose of the audits is to establish whether all clinicians are disposing of clinical waste products in accordance with statutory regulations and also to re-assess the position of sharps boxes, ensuring that they were not accessible to children.

The last audit was conducted in March 2023.

All sharps box locations were found to be appropriate and safe and did not require relocation. Some Consulting and treatment rooms were improved in order to guarantee all hooks were effectively placed on the walls.

The audits are repeated at three monthly intervals to ensure good practices are maintained on a daily basis by all clinicians and staff members.

The audits which involve checking consulting and treatment rooms are completed on a monthly schedule and they have been carried out by Monika K and Paulina P.

Toilets are checked in the morning and cleaned at mid-day after morning surgery and a full cleaning of these premises are performed out of hours daily.

The clinical evidence carried by the responsible members are kept up to date and for reference their folders may be checked.

In all room and utilities areas Hand wash Hygiene Technique data sheet were checked and replaced when necessary due to poor state of repair.

A hand sanitizer was supplied to clinicians for their visiting bags for home visit.

Risk Assessments and outcomes

Risk Assessments are carried out to ensure that the practice can review potential risks and ensure that steps are taken to minimise the impact of these risks.

Our infection control lead carried out an infection control inspection in March 2023 when the quarterly internal audit would have taken place.

The cleaning is outsourced to a company called Thorokleen. Catherine is the supervisor in charge of the team of cleaners who are responsible for cleaning the Practice. Regular meetings are held with the cleaning supervisor and Rachana Khatri and the management team based on evidence of cleaning issues identified by the infection prevention and Control team. We have meetings every Wednesday with Catherine Horseman.

The following actions were needed: 

  • Proper cleaning of rooms in some areas with further supervision required:
    1. Action Plan: the cleaner’s supervisor – Catherine was to complete and supervise the general audit as per job specification in the general cleaning process of those areas.
    2. The last cleaning meeting with all cleaners and leads took place on 16.03.2023. For reference please see Appendix III – Minutes of the meeting.
    3. Attendees at the meeting were: Catherine, and Juta, Elzbieta, Gherghina, Dorata and Victoria Topics discussed were as follows:
  • General overview of the cleaning areas with the responsible cleaners affected to each one (Appendix IV);
  • Working patterns
  • Cleaning duties when covering for colleagues
  • Curtain Cleaning SOP discussed
  • Discussed waste protocol
  • Mopping System
  • Holiday cover for cleaners

Training for staff

  • Hand Washing Techniques Assessment and Panic Alarm
  • Training completed on 09/12/2022
  • Training for new staff and the update for the current staff.
  • Main topics  were discussed:
  • Good Hand Washing Guide with 6 steps
  • When to press the panic button
  • How to use the panic button
  • What happens when panic  button  is pressed
  • Fire Marshall Training
  • Training completed on 06/03/2023
  • Main topics were discussed:
  • Online mandatory training on Clarity
  • Planning future F2F Fire Marshall Training for Staff with John Rogelt in May 2023.

Infection Control and Health & Safety Training was provided by Dr Neil Modha on 09/12/2022.

The following topics discussed at this meeting:

  • Sharp Disposal
  • Needle stick injury
  • Chain of Infection
  • Bags-correct waste segregation
  • Hand washing
  • Panic Alarm

Legionella Risk Assessment at Thistlemoor Medical Company is undertaken by a company ‘Yes! Results’.

The responsible person at Thistlemoor Medical Centre is Administrator is Rachana Khatri and assisted by Stanislaw Klosowicz.

The Risk Assessment was done on 10/11/2021 and its next inspection is due to be in November 2023 (review due is 10/11/2023).

Legionella risk assessment and actions taken document together with the risk assessment are available in the evidence folder for Infection prevention and control.

For evidence and reference the physical folder is ought to be consulted with Rachana Khatri. All recommendations are in place and working fully.

Action Plan from last Risk Assessment: a meeting with Rachana Khatri to check the full documentation was in place.

  • Legionella Risk Assessment Protocol has been reviewed in September 2022. The next review is planned in September 2023.
  • Safe Water Policy has been reviewed in April 2022. The next review is planned in April 2023.

Waste Management

All staff is responsible for the safe management and disposal of waste and should understand how waste should be segregated and stored prior to collection or disposal.

The Practice has a general duty to ensure the health and safety of employees and other persons who may be affected by the storage, handling or disposal of waste products. It is essential that waste is disposed of in a proper manner and that the method of disposal, and the standard of record keeping, complies with both legislation and best practice.

All staff required to handle clinical waste are given adequate instruction about the risks associated with, and the procedures to be used, in order to ensure the safe handling, segregation and storage of clinical waste.

In addition to this all staff are made aware of the procedures to be used following a spillage, and receive COSHH training at least annually, or as relevant to their role.

Waste Management Audit was undertaken and training took place, as some of the waste was not separated correctly to comply with recycling requirements and a demonstration was provided for assembly of Sharp bins and correct colour coding for disposal of sharps contaminated with only blood, with medication and with cytotoxic medication.

Action Plan:

To update all staff on waste management.

To have a cleaners’ meeting to discuss waste management.

The general waste management training was provided Dr Neil Modha in March 2022. Discussing waste management, hand hygiene and handling of vaccinations.

The refresher trainings to update new staff about waste management were provided by Dr Neil Modha on 22/09/2022 and 09/12/2022 during the Practice Meetings.

Handling of vaccinations have been discussed with Staff during Venepuncture Training held on 20/07/2022 and on 12/10/2022.

Cleaners meetings held at Thistlemoor Medical Centre by Rachana Khatri.  The last cleaners meeting took place on the 16/03/2023 to ensure that all cleaners are aware of the waste protocol. They were reminded about use of recycle bins and changes accordingly.

Outcome of meetings:

  • Introduction of a new mopping system, some improvement seen on the surgery floor.
  • Ensured consistent cleaning standards are maintained during holidays by improving  holiday cover
  • We discussed waste management with a cleaning staff on the following meetings as well: 12/01/2023.

Attenders of Cleaners Meeting hold on 16/03/2023:

All Cleaners:

Juta, Elzbieta, Gherghina, Dorata and Victoria.

  • This was a general meeting to inform the cleaning team to continue with the risk of Covid and the expectation from them and to answer any of their queries.
  • We have informed the cleaner’s that in case of emergency when we get any patient who could be suspected case of Covid we would call them to come in and deep clean the consulting rooms and would provide them PPE for single use.
  • A COOSH Assessment was done as well to guarantee the cleaners were aware of the storage arrangements, first aid and PPI (Appendix V).
  • The last risk COOSH Risk Assessment was completed by Roszia Bi in July 2022 and the next one is planned in 1 year time- July 2023. The responsible person to complete the next risk assessment is Roszia Bi.

Staff training

Staff are up to date with their infection control training delivered by Dr Neil Modha in two general meetings:

Dates of the three meetings: 09/12/2022

  • Sharp Disposal
  • Needle stick injury
  • Chain of Infection
  • Bags-correct waste segregation
  • Hand washing
  • Panic Alarm

The previous discussion of Infection Control meeting was on 22/09/2022

  • Disposal
  • Spillage
  • Clinic Room
  • Sharp Bins
  • PPE

Additionally, handling of vaccinations have been discussed with Staff during Venepuncture Training held on 20/07/2022 and on 12/10/2022.

The Infection Control training included the following areas:

  • Aims of the Infection Control Policy;
  • Infection Control in the practice;
  • Infections: transmission, standard universal precautions and prevention;
  • Maintaining the cold chain;
  • Hand washing technique;
  • PPE;
  • Spillage;
  • Waste management and types of waste;
  • Correct assembly and disposal of yellow sharp bin;
  • MRSA: Peterborough City Hospital Protocol and case study.

This training is generally provided twice a year to involve all new staff and as an update and refreshment of knowledge and good practices in our surgery.

The last Infection Control Training held on 09/12/2022 which included chain of infection, sharp disposal, waste management and hand hygiene. This has also been added as staff training.

PPE (Personal Protective Equipment) 

The practice provides PPE for all members of the team in line with their role.

  • PPE audits completed by Monika Klosowicz and Paulina Piatkowska in March 2023 were done throughout and quarterly during the period of 1st April 2022 to 31st March 2023 and this is continued in 2023-2024 by Paulina P and Roszia B.
  • Evidence is available for reference in the Infection Control Audit Folder.
  • We discussed PPE with our cleaner’s staff on the meeting held on 20/12/2022 and 16/03/2023 and the staff on the Practice Meeting on 22/09/2022.


Clinical waste is categorised and stored in line with our waste management policy and collected fortnightly

  • Domestic waste is disposed of via a contract with the local council. Collections take place monthly.
  • Confidential Waste stored in a locked console is collected once monthly via contract.
  • Clinical Waste is collected every fortnight by SRCL.
  • Cardboard & Non Confidential Paper waste are being shredded by another company once a month.
  • Audits have been completed quarterly by Rachana Khatri, Nadia Batul, Rosie Mahmood
  • Last audit completed by Nadia Batul, Rosie Mahmood in January 2023.
  • Evidence is available for reference in the Infection Control Audit Folder.

Fixtures, Fittings & Furniture 

  • Seating audit completed in March 2023. Monthly checks being done by Stanley.
  • Waiting area chairs / couches that needed repair have been repaired and replaced in July 2022 Currently there are no chairs for replacing since last replacement.
  • Patients Chair have been replaced in Zone A and B in August 2022 with wipe able chairs and other chairs have been repaired for wear and tear. Regular checks done.
  • There were also some major repairs to the ceiling and walls done in the period between 01/04/2022-31/03/2023.


  • Patients who are thought to have an infection that may be contagious i.e. Covid or other infectious diseases like chickenpox are asked to wait in a designated isolation room rather than the main waiting room. The reception staff has been informed to isolate these patients.
  • Staff follow the procedures for Covid which were specially created during the pandemic and are found in the infection control folder.
  • There have been no reported cases of MRSA acquired in the practice since last annual statement.
  • In regards to minor surgeries done in the surgery there are no reports of infection, uterus perforation on bleeding as a consequences of the procedure.
  • Procedures carried out: Coils and Nexplanon insertion and removal.

Policies, procedures and guidelines

All policies, procedures are in Health & Safety Folder and Infection Prevention Control Folder.

Responsibility for ensuring its policies and protocols is followed: Dr Nalini Modha and the infection control team and every staff member.

Catherine Horseman from the Cleaning Company Thoroghcleen is responsible for regular monitoring of the standard of cleaning throughout the practice and reporting to the cleaners if any problems are identified.

Catherine Horseman is responsible for liaising directly with the cleaners alongside Clinical Manager Dr Nalini Modha who will be informed if any issues are identified which need further escalation.

Our Annual Statement of Infection Control is uploaded onto our practice website:

Annual Statement of Purpose and Infection Control 2022-2023.

Next Annual Statement due: April 2024

Team Responsible: Dr Nalini Modha, Nadia Batul, Rachana Khatri, Roszia Bi, Paulina Piatkowska, Monika Klosowicz