IPC Annual Statement Report

Infection Prevention and Control (IPC) Annual Statement 2026/27

• Reporting Period: October 2025 to September 2026
• IPC Lead: Sally Greenslade, Nurse Manager
• Practice Manager: Amy Taplin

Introduction

In accordance with the Health and Social Care Act 2008: Code of Practice on the Prevention and Control of Infections and Related Guidance, this annual statement outlines the arrangements in place to minimise the risk of healthcare-associated infection within Pinhoe Surgery and Broadclyst Surgery. This statement provides a summary of infection prevention and control (IPC) activities undertaken during the year, audit findings, identified risks and planned improvements.

IPC Leadership and Governance

The practice has a nominated IPC Lead, Sally Greenslade (RGN), who is responsible for overseeing infection prevention and control arrangements across both sites. The IPC Lead is supported by the Practice Manager and Partners to ensure compliance with national guidance and local policies.

The practice has access to current IPC policies and procedures, and staff receive regular infection prevention and control updates and mandatory annual training. Staff are able to access IPC policies, guidance and resources via ‘useful links’ on Teamnet.

No known infection transmission events were identified within the practice during the reporting period October 2025 to September 2026. IPC-related incidents and significant events are monitored and investigated where appropriate, with any learning and resulting actions shared with relevant staff.

IPC Audits Undertaken

During September 2026, comprehensive annual Standard Infection Control Precautions (SICP) audits were completed at both sites using the Harrogate and District NHS Foundation Trust Annual IPC Audit Tool.

In addition to the annual SICP audits, and in accordance with the practice Infection Prevention and Control Policy, a programme of observational audits and competency assessments have been undertaken throughout the year to provide assurance that staff continue to comply with the requirements of Standard Infection Control Precautions (SICPs). These audits form part of the practice's wider IPC quality assurance programme.

Hand Hygiene Compliance Audits

A hand hygiene compliance audit was undertaken across both practice sites on 21 September 2026 by Sally Greenslade, IPC Lead. Ten members of staff representing a range of clinical roles were observed, including GPs, nurses, HCAs and allied healthcare professionals. All staff observed demonstrated full compliance against the audit criteria.:

• The "5 Moments for Hand Hygiene".
• Bare Below the Elbows requirements.
• Appropriate hand hygiene technique.
• Appropriate disposal of paper towels.
• Appropriate management of cuts and grazes where applicable.

Personal Protective Equipment (PPE) Audit

A PPE competency audit was completed on 17 September 2026. The assessment demonstrated full compliance with PPE requirements, including:

• Bare Below the Elbows compliance.
• Appropriate selection of PPE based on risk assessment.
• Correct use of clinical aprons.
• Correct sequence for donning and removing PPE.
• Appropriate disposal of PPE into the correct waste streams.
• Suitable uniform and footwear standards.
• Appropriate cleaning of reusable PPE.

The assessment identified no concerns, and the staff member demonstrated a good understanding of PPE requirements and the importance of maintaining aseptic "no-touch" principles where appropriate

Aseptic Technique Competency Assessment

An annual aseptic technique competency assessment was undertaken on 17 September 2026 for a practitioner during a minor surgery clinic. The assessment was conducted by Sally Greenslade.

The highest competency score (Level 2) was achieved across all assessment criteria, demonstrating:

• Excellent understanding of the principles and purpose of aseptic technique.
• Knowledge of when aseptic technique should be used and when it would be inappropriate to proceed.
• Correct hand hygiene and sterile glove application techniques.
• Maintenance of a sterile field throughout procedures.
• Appropriate use of PPE.
• Safe disposal of sharps and clinical waste.
• Effective decontamination of equipment and surfaces.
• Maintenance of patient dignity, privacy and comfort.
• Excellent communication and consent processes.

The assessment concluded that the practitioner was fully competent to undertake aseptic procedures independently and demonstrated good clinical practice throughout the assessment.

Ongoing Audit Programme

Monthly hand hygiene observations continue to be undertaken by the IPC Lead, alongside annual competence assessments in hand hygiene, aseptic technique and PPE use. Findings are shared with relevant staff and are used to identify learning opportunities and support continuous improvement in infection prevention and control standards across both practice sites.

Overarching Annual SICP Audit Results

Broadclyst Surgery

• Overall compliance score: 98.1% (Green Rating).
• High levels of compliance were demonstrated across all ten SICP standards.
• Minor improvements identified related to poster display, upgrading older taps to single-lever mixer taps, and consideration of wall-mounted sharps containers.

Pinhoe Surgery

• Overall compliance score: 91.3% (Amber Rating).
• Areas achieving full compliance included patient placement, respiratory hygiene, waste management, blood and body fluid spillage management, and care equipment management.
• Several areas requiring improvement were identified, largely associated with the significant building refurbishment and extension programme currently underway.

Significant Findings and Risks Identified

The principal IPC risks identified during the year related to the ongoing refurbishment and extension works at Pinhoe Surgery. These included:

• Temporary loss of handwashing facilities within four consultation rooms during construction works.
• Historic clinical rooms without dedicated handwashing facilities.
• Dust accumulation associated with building works.
• Areas of the building requiring repair and refurbishment.
• Limited availability of fresh air ventilation in older clinical areas.
• Some couch pillows requiring replacement to meet IPC standards.
• Historic gaps within staff immunisation records which continue to be reviewed and addressed.

The audit concluded that despite these challenges, temporary mitigation measures were in place throughout the construction period, including freestanding handwashing facilities and ongoing environmental monitoring.

IPC Risk Assessments

IPC-related risks were assessed throughout the reporting period, particularly in relation to the ongoing refurbishment and extension works at Pinhoe Surgery. Risks identified included temporary changes to handwashing facilities, dust and environmental cleanliness, ventilation, the condition of clinical areas and staff immunisation status. Appropriate control measures were implemented and monitored throughout the works, including temporary handwashing facilities and ongoing environmental monitoring.

Actions Taken During the Year

The practice has:

• Continued monthly hand hygiene auditing.
• Undertaken annual SICP, PPE and environmental audits.
• Maintained staff IPC training and competency updates.
• Ensured appropriate stocks of PPE and cleaning products are available and monitored.
• Maintained systems for waste segregation and sharps management.
• Used Polymer Gel for safe disposal of urine samples during periods when sluice facilities were unavailable.
• Continued review of staff immunisation records and offered further vaccination or disclaimers where evidence of immunity is unavailable.
• Progressed a significant building programme designed to modernise facilities and improve IPC compliance.

Planned Improvements for 2026/27

The practice has developed an action plan arising from the IPC audit. Key actions include:

• Completion of the Pinhoe Surgery extension and refurbishment project.
• Reinstatement of handwashing facilities in all clinical rooms.
• Installation of handwashing facilities within all treatment rooms.
• Introduction of single-lever mixer taps within all newly developed clinical areas.
• Installation of fresh air ventilation systems within new treatment rooms.
• Display of additional IPC posters, including hand hygiene, bare below the elbows, sharps injury and PPE guidance.
• Review of wall-mounted sharps container options.
• Replacement of couch pillows and covers where required.
• Completion of outstanding staff immunisation record reviews.
• Ongoing monitoring of environmental cleanliness following completion of building works, including consideration of a post-build deep clean.

Staff Training

All staff complete mandatory infection prevention and control training and receive regular updates appropriate to their role. New staff receive IPC information and training as part of their induction, with ongoing mandatory training completed thereafter. Staff are expected to maintain awareness of standard infection control precautions and have access to supporting guidance and policies.

Review of policies, procedures and guidance

IPC policies, procedures and supporting guidance are reviewed and updated in accordance with the practice's policy review arrangements and relevant national guidance. Current IPC policies, procedures and supporting resources are available to staff via TeamNet, with relevant updates communicated to staff where required.

Healthcare Associated Infections

The practice monitors infection prevention and control issues and investigates significant events where appropriate. No themes were identified through the annual audit process that suggested systemic failings in infection prevention and control arrangements during the reporting period.

Conclusion

Pinhoe and Broadclyst Medical Practice remains committed to maintaining a safe environment for patients, visitors and staff. Audit findings demonstrate strong overall compliance with infection prevention and control standards, particularly at Broadclyst Surgery. The ongoing refurbishment programme at Pinhoe Surgery is expected to address the remaining environmental and infrastructure-related IPC risks and further strengthen compliance during 2027.

• Approved by: Amy Taplin, Practice Manager
• IPC Lead: Sally Greenslade, Nurse Manager / IPC Lead
• Date: 7th October 2026