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Infection Control Annual Statement 2025-26
📌Purpose
This annual statement is published in line 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 provides a summary of the infection prevention and control(IPC) activity across all First 4 Health Group sites, including:
● Any infection transmission incidents and actions taken
● Infection control audits completed and subsequent actions
● Risk assessments carried out for infection prevention
● Staff infection control training
● Review and update of relevant policies, procedures, and guidelines
Infection Prevention and Control Leadership
Our Infection Prevention and Control (IPC) Lead is Dr Bhupinder Kohli (GP Partner).
Audits and documentation are managed by:
● Maisy Binion (Group Practice Manager)
● Sahima Khanom (CQC and Facilities Lead)
Each practice site also has designated leads responsible for conducting monthly internal infection control audits:
Church Road Health
● Definite Mabhodo-Chiweshe (Practice Nurse)
● Jahanara Khanom (Nurse Associate)
● Sahima Khanom (F4HG CQC and Facilities Lead)
Stratford Village Surgery
● Fay-Vincent Dorgan (Health Care Assistant)
● Stefania Apostol (Health Care Assistant)
● Felicenne Tekilazaya (Practice Nurse)
● Sahima Khanom (F4HG CQC and Facilities Lead)
Glen Road Medical Centre
● Jaynnes Mwaniki (Practice Nurse)
● Beverley Biggs (Practice Nurse)
● Iqbal Hossain (Health Care Assistant)
● Sahima Khanom (F4HG CQC and Facilities Lead)
E7 Health
● Kalsuma Khatun (Practice Nurse)
● Rahat Rana (Health Care Assistant)
● Sahima Khanom (F4HG CQC and Facilities Lead)
As of July 2025, all site leads have completed up-to-date infection control training.
📋 Significant Events
Significant events related to infection control are recorded and reviewed to promote learning and service improvement. These are reported via our internal system(Teamnet) and escalated when required.
🔹 Church Road Health – 06 June 2025
Incident: Vaccines were left unrefrigerated on the reception desk for ~30 minutes post-delivery.
Root Cause: The reception team were unaware of cold chain procedures.
Actions Taken: Manager intervened, nurse consulted UKHSA for advice on vaccine safety.
Learning:
● Cold chain training to be included in induction for admin staff.
● Additional fridges discussed for better access when clinical rooms are unavailable.
🔹 Stratford Village Surgery – 10 October 2024
Incident: During a child’s immunisation, the assisting parent was pricked by the needle, causing concern about continued vaccine use.
Root Cause: Nurse required physical support during the procedure.
Actions Taken: Incident reported by parent and escalated to the APM.
Learning:
● Any compromised needle must be replaced.
● Documentation of incidents and conversations during consultations is essential.
● The nurse revisited infection control training.
● Discussed with APMs (FK & ZA) and Medical Director (MC).
🔹 Glen Road Medical Centre – 26 March 2025
Incident: Vaccine fridge was left open for 20–30 minutes.
Root Cause: Fridge not properly closed.
Actions Taken: Issue was identified quickly; fridge closed and temperatures reviewed. No breach occurred.
Learning:
● Staff reminded to ensure fridges are securely closed.
● Fridges are now locked at the end of each day.
🔹E7 Health
No infection control incidents were reported during this period.
🧪Audits
A full 5-yearly Infection Prevention and Control Audit was conducted by NHS England on 7 March 2024, with the next due in March 2029.
All sites also carry out monthly internal IPC audits.
⚠ Risk Assessments
Annual and ongoing risk assessments completed include:
● Legionella (Water Safety): Ensures water systems are safe for patients, visitors, and staff.
● Immunisations: Staff are offered and encouraged to maintain up-to-date protection, including Hepatitis B, MMR, Flu, and COVID-19vaccines.
● COSHH (Control of Substances Hazardous to Health): Reviewed regularly by CQC and Facilities Lead.
● Cold Chain (Vaccine Storage): All sites use a quarterly self-audit tool to assess cold chain compliance.
🧹 Cleaning and Hygiene
All practices follow site-specific cleaning protocols. Cleanliness is assessed monthly as part of IPC audits. This includes equipment checks and reviewof responsibilities between staff and property owners.
🎓 Staff Training
All staff receive annual infection control training, with new starters completing training within their first few days.
Staff with specific roles complete additional e-learning on:
● Legionella
● COSHH
📁 Policies and Procedures
All infection control-related policies are up-to-date and are regularly reviewed in line with changes to national guidance.
Policies are made available via MS Teams, and staff are reminded of their locations during monthly team meetings.
🙋 Responsibility
Every team member is responsible for adhering to infection control protocols and familiarising themselves with this statement and their role in maintaining a safe clinical environment.
***Last Updated 03/07/25
