Annual Statement of Infection Control updated April 2023

 

 

Purpose

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.

 

Background

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.

Audits

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 1^st April 2022 to 31^st 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.

Waste 

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

• 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

 

 

Statement of purpose (as of February 2022)

The name and address of the registered provider is:

Thistlemoor Medical Centre
6-10 Thistlemoor Road
New England
Peterborough
www.thistlemoor.co.uk

Registered Manager: Dr. Neil Modha
Practice Manager: Ms. Paulina Janczura
Legal Status: Partnership
Service Types: Doctors Consultation Service
Doctors Treatment Service

Regulated Activities:

Treatment of disease, disorder or injury

Surgical Procedures

Diagnostic and Screening Procedures

Maternity and Midwifery

Family Planning Service

Vaccination services

Service Users:

Open for Registration to patients resident and temporarily resident on the practice area.

The medical centre has existed for over 50 years and started as a single building. The practice has been completely remodelled over its history to now consist of purpose built facility within modern premises. The practice also has large onsite parking. We have been a training practice since 2010.

Due to Coronavirus we have developed an external site for flu and coronavirus vaccination delivery. This involves 3 vaccine cabins towards the rear of the Practice near the Staff Car Park.

Under the Health and Social Care Act 2008 (The Care Quality Commission (Registration) Regulations 2009 Part 4), the registering body (Thistlemoor Medical Centre) is required to provide to the Care Quality Commission a statement of purpose.

Our Aims and objectives:

• Provide a high standard of Medical Care
• Be committed to our patients needs
• Act with integrity and complete confidentiality
• Be courteous, approachable, friendly and accommodating
• Ensure safe and effective services and environment
• To maintain our motivated and skilled work teams
• Through monitoring and auditing continue to improve our healthcare services
• Maintain high quality of care through continuous learning and training
• Ensure effective and robust information governance systems
• Treat all patients and staff with dignity, respect and honesty
• Ensure that every individual is treated fairly and without discrimination

Our purpose is to provide people registered with the practice with personal health care of high quality and to seek continuous improvement on the health status of the Practice population overall. We aim to achieve this by developing and maintaining a happy sound Practice which is responsive to people’s needs and expectations and which reflects whenever possible the latest advances in Primary Health Care.

We aim to offer our registered patient population a service they are satisfied with; our vision statement is “The service we provide is the service we are happy to receive”. If however, you are dissatisfied with service you receive from any of the Doctors or other member of the practice team please let us know to enable us to resolve the matter. We operate a practice complaints procedure inline with NHS Guidance.

We hope that most problems can be sorted out easily and quickly following a telephone conversation with the Complaints Manager Roszia Bi. She helps our patient relations work and will try her best to resolve most problems.

We would also ask for your consideration when providing feedback. Feedback is really helpful as it helps us consider ways of improving our service, but we would appreciate some consideration in the way you provide feedback to us. In the same way that someone provided feedback to you in your job or in your raising of a family.

If you do have a problem you would like dealing with in this way please leave your telephone number with a member of our Reception Team and Roszia will call you back within 2-5 working days. Please note Roszia are unable to speak to patients face to face without a pre-booked appointment. We aim to investigate within 10-15 working days and respond to the complaint within a further 5-10 days. All complaints are sent to our legal advisors to comment which is why the process takes extra time. This may be even longer in complex situations (for example when many different clinicians were involved) or where care was delivered by other health providers. You may be signposted to complain to the service directly or to other support organisations that can help you with this.

The practice adheres to the strict rules in place relating to patient confidentiality. If you are complaining on behalf of someone else, we have to be assured that you have his or her permission to do so. A consent form signed by the patient concerned will be required by the practice, unless they are incapable (because of illness) of providing this to enable the practice to carry out an investigation.

If your concerns cannot be addressed by speaking to Roszia Bi please click on the link below which gives full details of our Complaints Procedure including a consent form which should be completed if you are complaining on behalf of someone else.

Read/Download the full Complaints procedure

To use our online complaints form please click here.

The NHS operates a zero tolerance policy with regard to violence and abuse and the practice has the right to remove violent patients from the list with immediate effect in order to safeguard practice staff, patients and other persons.

Violence in this context includes actual or threatened physical violence or verbal abuse which leads to fear for a person’s safety. In this situation we will notify the patient in writing of their removal from the list and record in the patient’s medical records the fact of the removal and the circumstances leading to it.

We believe that it is important to protect our staff and other patients or visitors.

We understand that the pandemic has been challenging, and recognise that many of us are struggling as a result of this. However, this is no reason for you or your carers to be rude, abusive or racist to us or out staff. If this happens – you will be written to to explain that this behaviour is unacceptable, this will be your final warning. If this happens twice, we will write to our commissioners and ask for your registration with the practice to be cancelled.

A simple guide – is please treat us the way you would like to be treated.

In order to provide care for you, we are obliged to keep records. We are a computerised practice and we comply with the Data Protection Act 1998 and other guidance on privacy and data confidentiality. In order to manage services and improve the quality of care we provide, we share some information on practice activity e.g. with The clinical commissioning group.

Wherever possible, the information is anonymous i.e. names and other identifying details are removed.

Information is NOT shared with any third party outside the Health Service (e.g. insurer, employer, and solicitor) without explicit consent and agreement. We are obliged by law to provide certain information e.g. notification of infectious diseases to Public Health Specialists.

Everyone working for the NHS has a legal duty to keep information about you confidential and adhere to a Code of practice on protecting patient confidentiality.

If you would like access to your medical records, please apply in writing to Paulina Janczura, Practice Manager.

What if I want to discuss my concerns about a family member or friend who is registered at your practice?

If you have serious concerns about a registered patient, please do not hesitate to let us know.

However, to respect out patient’s confidentiality we are unable to discuss the contents of any patient’s records with a family member or friend without written consent from that patient allowing us to do so.

The exception to this is when a parent wishes to discuss their child’s health. If a child under 16 consults about contraception, the parent is not entitled to access that information, although it is accepted practice for the doctor or nurse to encourage the child to discuss the contraception with his or her parents / guardian.

General practices are required to publish the average earnings per General Practitioner for the year 2020/2021.

For Thistlemoor Medical Centre, the average earnings per GP is £77,800. This is based on 7 Full-time and 8 Part-time Doctors and takes into account NHS income against expenses without deductions of Tax or national insurance.

At our medical centre we aim to provide our patients with the best quality care available. Our charter is a statement of what you can expect from this practice and what we feel we can expect in return from you.

All patients will be treated equally. We do not discriminate on the grounds of gender, gender identity, race, disability, sexual orientation, religion or age.

Our premises will be clean and comfortable and have facilities for the disabled

All patients will be greeted in a friendly manner and be treated with courtesy by everyone in the practice.

Strictest confidentiality should be expected.

Patients will be offered advice about how to stay healthy and avoid illness

New patients registering with the practice will be offered a health check

Patients will be referred to a specialist when the doctor feels this is necessary

Complaints will be dealt with by our complaints manager who will refer complaints to the doctors where appropriate

We Aim

• To offer patients a consultation with a healthcare professional within 24 hours during the working week. Due to the current coronavirus pandemic this will be mainly delivered by the telephone or video consultations.
• To see all patients with genuine urgent problems as soon as possible.
• To provide appointments in the afternoon for patients. Although patients should understand that for routine appointments there may be a wait of several days or weeks.

Policy On Patients’ Rights

In relation to primary care, patients have certain rights.

A patient has the right to;

• be on a practice list
• have a consultation with a clinician (this depends on availability and does not need to be their named GP) at the medical centre. Nurses can manage many of the conditions previously managed by GP’s and are the first port of call for many patients. If a nurse cannot manage the condition they will discuss this with their supervising clinician.
• have access to a telephone number where a signposting service can be reached 24 hours a day, every day of the year. This should preferably be a home telephone number.
• have a home visit if the patient lives within the practice boundary, if considered necessary by the GP.If temporarily away from home must receive treatment if it is considered to be required immediately, though the GP is not bound to accept them as a temporary resident.
• be prepared to wait for an appointment. Routine appointments may need a wait of more than 15 days depending on the demands on the service.
• change practice, by applying to another practice. No reason is required
• be entitled to a chaperone during examinations
• not bound legally to accept treatment. However, a doctor can give essential treatment if the patient is temporarily incapable of understanding or consenting to treatment as per the Adults with Incapacity Act
• refuse to be examined when a medical student or other trainee is present
• be entitled to a full and truthful answer to questions unless the answers would result in anxiety, which may injure the person’s health
• complain about their GP if he has not followed his terms of service or behaves in an unprofessional or unethical way. The patient should then be kept informed about how the complaint is being dealt with and told of the outcome
• see medical reports requested by insurance companies or employers before they are forwarded. However, a GP may withhold them if access may cause harm to the patient or if they contain information regarding a third party
• confidentiality

With These Rights Come Responsibilities

We ask that patients attend their appointments at the arranged time. If they cannot attend they will inform the medical centre immediately

We expect that patients will understand that appointments are for one person only. Additional appointments will be made if more than one person needs to be seen

Patients are responsible for their own health and the health of their children and should co-operate with the practice in endeavouring to keep themselves healthy

We ask that requests for help or advice for non-urgent matters be made during surgery hours

Home visits should only be requested for patients who are seriously ill and live within the practice boundary. It is important to bear in mind that most medical problems are dealt with more effectively in the clinical setting of a well-equipped medical centre.

Patients should understand that home visits are made at the doctor’s discretion

Many problems can be solved by advice alone, therefore patients should not always expect a prescription at every consultation

We ask that patients treat the doctors and staff with courtesy and respect.

Patients must inform the practice staff of any alterations in their circumstances, such as change of surname, address or telephone number, even if it is ex-directory

We ask users of the service to be patient, to expect a waiting time in our morning surgeries and to be prepared to wait several days for a routine appointment. This allows us to prioritise care for those who are most in need of medical attention.

We ask our patients to understand the rise in demand for general practice services and understand the difficulties in recruitment that can lead to pressures on our service and longer waiting time for emergency and routine appointments.

Suggestions

We welcome comments on the services provided. These should be directed to one of the partners or to the practice manager, Ms Paulina Janczura.

 (Updated August 2021)

Read/Download our Privacy Notice

Read/Download our Data Protection Impact Assessment (DPIA) Policy

Statement

The recording of data within the practice is under the management and control of Dr Nalini Modha, who is the Clinical Governance and IT lead GP for the practice.

The quality of data, the use of templates and the use of specific coding is reviewed on an ongoing basis and the findings are discussed at weekly clinical policy meetings, where examples of coding issues are cited as appropriate.

Dr Nalini Modha and Dr Neil Modha is responsible for overall coding and data quality issues within the practice and will ensure accuracy and consistency in coding among both the clinicians and the administrative or casual staff.

Agnieszka Soczowka is the non-clinical manager responsible for audit and exception identification and reporting within the practice.

This responsibility is supported by frequent audit and validation of data using QOF and other tools, and is supported by a data administrator employed for this purpose.

The Clinical System, SystemOne is responsible for distributing updates Read / SNOMED codes as and when they become available.

Any queries should be addressed to the lead GP.