Infection Control

Infection control annual statement

Tollgate Medical Centre

Annual infection control statement 2024-2025

This annual statement will be generated each year in February.

It is a requirement of the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance that the Infection Prevention and Control Lead produces and annual statement with regard to Compliance with good practice on infection prevention and control.

It summarises:-

  • 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 prevention and control of infection.
  • Details of any staff training.
  • Any review and update of policies, procedures and guidelines.

Infection Control Lead

The practice’s clinical lead for infection control is Carol Hastings, Nurse Manager

The infection control lead has the following duties and responsibilities within the practice:

  • Keep up to date with changes in Infection Control
  • Check PPE
  • Checking the Surgery for Cleanliness
  • Performing infection control related audits
  • Reporting any significant events or updates to the wider team

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 might lead to future improvements.  All significant events are reviewed in the monthly full Practice Meetings and learning is cascaded to all relevant staff.

As a result of these events, Tollgate Medical Centre has:

-Continued with bi-annual infection control updates for both clinical and non-clinical staff.

-Ensure infection control guidance remains accessible to all staff.

-Training is logged on Blue stream and in Personnel Files.

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


Infection Prevention Audit and Actions

The practice carries out an Infection Prevention and Control audit every 6 months, the last audit was completed in October 2023. This involves a comprehensive review of all aspects of infection prevention and control within the surgery.

As a result of this audit, the following changes are planned:

  • Caretaker to repair and paint damaged wall surfaces (Ongoing).
  • Damaged couch in Room 16 to be repaired (Completed 24/01/24)

Risk Assessments

Risk assessments are carried out annually so that best practice can be established and then followed.  In the last 12 months the following risk assessments were carried out/reviewed.

  • Legionella (Water) Risk Assessments: The practice reviews its water safety risk assessment to ensure that the water supply does not pose a risk to patients, visitors or staff (Completed 14/04/23).
  • Cleaning specifications, frequencies and cleanliness: We work with our cleaners to ensure that the surgery is kept as clean as possible. Monthly assessments of cleaning processes are conducted with our cleaning contractors to identify areas for improvement
  • Immunisation: As a practice we ensure that all our staff are up to date with their Hepatitis B immunisations and offered any occupational health vaccinations applicable to their role (i.e. MMR, Seasonal Flu and Covid vaccination). We take part in the National Immunisation campaigns for patients and offer vaccinations via in house and via home visits to our housebound patient population.
  • Curtains: Disposable curtains are used in clinical rooms and are changed every 6 months.  All curtains are regularly reviewed and changed more frequently if damaged or soiled.
  • Hand washing sinks: The practice has clinical hand washing sinks in every room for staff to use. Some of our sinks do not meet the latest standards for sinks but we have mitigated this by: removing plugs; covering overflows and reminding staff to turn of taps that are not ‘hands free’ with paper towels to keep patients safe. We have also replaced our refillable liquid soap wall mounted soap dispensers with dispensers that accept sealed cartridges to prevent any cross contamination.
  • Tollgate Medical Centre undertake the following audits:
  • Infection control audit (6 monthly) last completed: 19/10/2023
  • Handwashing audit for all clinical and non-clinical staff (Annually)
  • Vaccine storage audit (Annually) last updated:  29/02/2024
  • Sharps bin (3 monthly) last completed: 25/01/2024
  • Monthly vaccination stock audits
  • Fridge temperature audits (Monthly)


All our staff receives bi-annual training in infection prevention and control via online learning on Blue stream.

Infection lead last update: 26/04/2023 (2-Day lead link practitioner course)

Hand Hygiene training and audit is carried out annually by our Lead Nurse for training and education.


All Infection Prevention Control related policies are in date.

Policies relating to Infection Control are available to all staff and are reviewed and updated bi-annually or as appropriate, and all are amended on an on-going basis as current advice, guidance and legislation changes.  Infection Control policies are available on Team Net for all staff to read.


It is the responsibility of each individual to be familiar with this Statement and their roles and responsibilities under this.

Review Date

February 2025

Responsibility for Review

The Infection Prevention and Control Lead is responsible for reviewing and producing the Annual Statement.

Carol Hastings (Nursing team manager)


If you have any concerns, questions or queries in regards to infection prevention control at the practice please email: [email protected] and we aim to respond to you as soon as possible.