GRMC Infection Prevention Control and Management Annual Statement Report 2023/2024


This annual statement will be generated each year in November 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 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 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 Gloucester Road Medical Centre is Niamh Stott, Treatment Room Team Leader.


Infection transmission incidents (learning events) 

  • Learning events involve examples of good practice as well as challenging events.
  • Positive events are discussed at meetings to allow all staff to be appraised of areas of best practice.
  • Negative events are managed by the staff member who either identified or was advised of any potential shortcoming. This person will complete a Learning Event Analysis form online that reflects the investigation process and provides the structure to establish what can be learnt and to indicate changes that might lead to future improvements.
  • All learning events are reviewed and discussed at a minimum of quarterly intervals or more frequently where more prompt review following an event is indicated 
  • Any learning points are cascaded to all relevant staff where an action plan, including audits or policy review, may follow. 
  • In the past year there have been 4 learning events raised that related to infection control. 3 of the incidents relate to needlestick injuries, and 1 ongoing issue with the supply of clinical waste products from TradeBe. There have also been 1 complaint made regarding cleanliness or infection control. This relates to the physical assessment of a patient without perceived adequate hand hygiene.
  • There has been a new cleaning company in place since April 2023, Green Machine. There are some ongoing issues where rooms are not always being cleaned according to their functional risk category. There is an ongoing escalation process with the company director. The proposed plan is a 3-month probationary period with monthly audits of the cleaning standards completed by myself, before a final review in June 2024.


Infection prevention audit and actions 

Detail information about the organisation and any requirements needed following the CQC inspection. The most recent CQC inspection was May 2018, with an annual review last conducted in July 2023, where the practice upheld the overall rating of ‘good’. There were no IPC related actions identified during this inspection.

Audit Frequency Responsible person
Infection Control, Prevention and Management Annual (May) Niamh Stott & Harriet Longman
Internal Inspection Annual (September) Harriet Longman & Amelia Bell
External Inspection Annual (May) Harriet Longman & Amelia Bell
Hand Hygiene Bi- annual (May & November) Niamh Stott
Sharps Management Annual (June) Niamh Stott
Clinical Rooms Quarterly Fran Clark
Cleaning Standards (external) Monthly Michelle Rellis (Green Machine Director)


Risk assessments  

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

  • Infectious Illness Mitigation (in response to Measles outbreak) (Feb 24)
  • Clinical waste management (November 23)
  • Infectious diseases (May 2023)



In addition to staff being involved in risk assessments and significant events, at Gloucester Road Medical Centre, all staff and contractors receive IPC induction training on commencing their post. Thereafter, all staff will now receive refresher training annually. As the new IPC&M lead, my priority for the next quarter is to facilitate the annual update for all staff, which will include sharps & waste management, specimen management, hand hygiene, equipment decontamination and general room cleanliness.


Quality Improvement

The following QI projects have been completed this year, in response to audit findings:

  • Fridge posters installed on all communal fridges; to remind staff to take their food home with them and reduce risk of cross contamination.
  • Removal of communal leg cleansing buckets for wound care; patients are now educated to self-care with this at home, where possible. 
  • ‘End of day’ cleaning checklist; for clinicians to complete to promote high cleaning standards across all treatment rooms.
  • Spill kit replaced with compliant spill kit (kept in business continuity box in reception).
  • Warning ‘infectious patient’ posters in each room; to be displayed when reviewing a potentially infectious patient.


Policies and procedures

The infection prevention and control related policies and procedures that have been written, updated, or reviewed in the last year include, but are not limited, to: 

  • Infection Prevention, Control and Management Policy (in progress)- Nov 2023

Policies relating to infection prevention and control are available to all staff and are reviewed and updated annually. Additionally, all policies are amended on an ongoing basis as per current advice, guidance, and legislation changes.  



It is the responsibility of all staff members at Gloucester Road Medical Centre to be familiar with this statement and their roles and responsibilities under it.  



The IPC lead and Harriet Longman are responsible for reviewing and producing the annual statement. 

This annual statement will be updated on or before May 2025.

Signed by:

Niamh Stott

Treatment Room Team Leader
For and on behalf of Gloucester Road Medical Centre