Infection control statement

Belvoir Health Group

Infection Control Annual Statement  2020

Created October 2020

Next Review October 2021


This 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/ Notifiable Diseases)

  • 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 Prevention and Control (IPC) Lead

Belvoir Health Group’s lead for IPC is Emma Mitchell

The IPC Lead is supported by : The Lead GP in infection control: Dr Anna Griffiths

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 may lead to future improvements. All significant events are reviewed in the monthly or weekly meetings and learning is cascaded to all relevant staff.

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

A commentary on the impact of Covid-19 on the operation of the organisation with regard to IPC is at the end of this statement.

Infection Prevention Audit and Actions

The Annual Infection Prevention and Control internal audit was completed by Emma Mitchell and Denise Bowler (Operations Manager) in January 2020. The resulting action plan has been reviewed by Emma Mitchell and Dr Anna Griffiths in October 2020.

As a result of the audit the following things occurred within in the practice:

  • Review of completion of mandatory annual hand hygiene education for clinical staff and follow up of defaulters
  • Review of completion of mandatory annual infection control training for all staff and follow up of defaulters
  • Replacement of tubes of lubrication jelly with single use sachets
  • Mop inverters installed in cleaners’ rooms (Cotgrave surgery)
  • Replacement of broken bin (Cotgrave surgery)
  • Minor repairs to separate staff and patient toilets (Cotgrave surgery)
  • Instigation of weekly cleaning schedules for shelves in clinical rooms (Cotgrave surgery)
  • Replacement of disposable privacy curtains- delayed delivery- in accordance with 6 month change policy (Cotgrave surgery)
  • Supply of purple bin to clinical room (Cotgrave surgery)
  • Removal of clutter from clinical rooms – all sites
  • Toys have been removed from waiting areas
  • Repairs to seals between wall and washable flooring (Bingham surgery)
  • Improved standard of hygiene achieved to baby changing area (Bingham surgery)
  • An improved standard of cleaning provided by contractors ( Cropwell Bishop surgery)

Consideration has been given to conditions not compliant or at risk of not being compliant with best practice in IPC as priorities when refurbishment of the premises occur.

  • Carpet in clinical / waiting areas (Cropwell Bishop and Bingham)
  • Lack of janitorial unit for emptying/filling mop bucket (Cropwell Bishop)
  • Fabric seats (Cropwell Bishop)
  • Cropwell Bishop does not currently have an outside clinical waste store – waste is collected directly from the rooms on a weekly basis. The situation is being monitored- may need to change with increased generation of clinical waste through increased use of Personal Protective Equipment

Risk Assessments

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

Annual Legionella risk assessment. To ensure that the water supply does not pose a risk of the infection Legionnaire’s disease to users of the premises.

Clinical staff underwent FFP3 respirator fit assessment

All staff underwent risk assessments after declared conditions to determine an individual’s risk in the event of contracting Covid-19 and therefore appropriate place of work during the different stages of the Covid-19 epidemic

Immunisation: The organisation has processes in place to ensure that staff are up to date with hepatitis B immunisation and are offered relevant vaccinations eg MMR, influenza


Staff receive training in IPC at induction and mandatory annual update currently provided via Bluestream Academy

Emma Mitchell and Dr Griffiths have undertaken eLFH modules on Infection Control this year

Staff have received information on use of Personal Protective Equipment and other IPC in relation to Covid -19 eg self isolation policy, handwashing /decontamination, patient isolation, decontamination of rooms and instruments,  maintaining social distancing and limiting patient numbers and flow within the buildings


Policies relating to IPC are in place and are available to staff. They are reviewed and updated annually or when necessary and new policies are added in line with changes in legislation and guidance. This year a Red Room policy has been introduced for seeing patients with respiratory symptoms and or a temperature during the coronavirus pandemic.



It is the responsibility of all employees to be familiar with this statement and individual roles and responsibilities within.


It is the responsibility of the IPC Lead and the lead GP for reviewing and producing the Annual Statement for and on behalf of Belvoir Health Group


The ongoing epidemic has introduced unprecedented challenges for our organisation for IPC and other domains. Referencing a combination of existing IPC principles and guidance and new national and CCG guidance Belvoir Health Group has adopted new working arrangements to limit the potential for spread of Covid-19 to patients and staff. A Covid committee was convened and continues to meet regularly to plan and review operations in keeping with latest guidance and information. Summary of changes implemented:

  • Reducing patient attendance at surgery- 1st patient contact via telephone, switch to ETP prescribing
  • Identification of most vulnerable patients
  • Identification and shielding of vulnerable staff- working from home
  • Access to testing- active coronavirus and arranging antibody tests for staff
  • Closing Cropwell Bishop surgery due to IPC risks and currently operating in a limited staff and patient capacity due to need for social distancing of staff and patients
  • Correct use of personal protective equipment, donning , doffing, disposal
  • Installation of hand hygiene stations
  • Arrangements for social distancing of patients in surgery and working staff
  • Installation of protective screens in reception
  • Operation of a red room for high risk patients needing face to face assessment on 1 site only and cleaning schedule
  • Procurement and monitoring of supplies of PPE, fit testing for FFP3 masks for clinicians
  • Education of staff and sharing of information
  • Adherence to self isolation policies
  • More intensive cleaning schedules
  • New arrangements for flu clinics
  • Limiting risks to staff during home visits

Dr A Griffiths 7.10.2020