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Infection Control Annual Statement

February 2024


This annual statement will be generated each year in February 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)
  • Details of any infection control audits undertaken and actions undertaken
  • Details of any risk assessments undertaken for prevention and control of infection
  • Details of staff training
  • Any review and update of policies, procedures and guidelines

Infection Prevention and Control (IPC) Lead

Holly Tree Surgery has two Leads for Infection Prevention and Control: Louise Upton, Practice 

Manager and Eleftherios Protopappas, Lead Practice Nurse

The IPC Lead is supported by: Dr Steve Scott-Perry and Louise Upton, GP Partnership 

Eleftherios attends regular IPC Lead training courses and keeps updated on infection prevention practice by attending local forums, educational events and online training.

Infection transmission incidents (Significant Events)

Significant 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 weekly partner meetings and learning is cascaded to all relevant staff.

In the past year there were no significant events related to infection control which reflected good practice and adherence to local and national policy.

Infection Prevention Audit and Actions

The Annual Infection Prevention and Control audit was completed by Summer Iwobi, IPC Lead, and Eleftherios Protopappas in February 2024

As a result of the audit, the following things have been changed in Holly Tree Surgery:

  • Cleaning schedules created for all rooms to ensure computer tops and fans are visibly clean.
  • Lead nurse to institute regular competency checks to ensure standards are maintained.
  • New sharps bins and brackets to be installed

Based on Public Health England notifications, the Practice is mindful of ongoing viral infections 

prevalence and appropriate measures and education is given.

No infections were reported for patients who have had minor surgery at the Surgery.

Holly TreeSurgery plan to undertake the following audit in 2025.

All staff to engage in a lunch and learn handwashing and infection control training session.

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:

Legionella (Water) Risk Assessment: The practice has conducted/reviewed its water safety risk assessment to ensure that the water supply does not pose a risk to patients, visitors or staff.

Immunisation: As a practice we ensure that all of 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, Covid). We take part in the National Immunisation campaigns for patients and offer vaccinations in house and via home visits to our patient population.

The cleaning schedules are laminated and in every consulting room 

Hand washing sinks do not all meet the requirements of CQC as they are not all elbow operated and this will be considered in any future relocation or development.


All our staff receive annual training in infection prevention and control.

All staff receive practical demonstration of handwashing every year. Online learning is compulsory via Blue Stream Academy.

Clinicians receive additional training regarding immunisations and health promotion according to their job role and are expected to provide certificates to the Practice Manager to be kept in their personal files.

Debbie Fielder performs water safety monthly temperature checks on all hot and cold water outlets as per HSE control of legionella recommendations.


All Infection Prevention and Control related policies are in date for this year.

The following policies are currently being updated:

Policies relating to Infection Prevention and Control are available to all staff and are reviewed and updated annually, and all are amended on an on-going basis as current advice, guidance and legislation changes.

Infection Control policies are circulated amongst staff for reading and discussed at meetings on an annual basis. 


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 and the Practice Manager are responsible for reviewing and producing the Annual Statement.

Summer Iwobi

Infection Prevention and Control Nurse NHS Frimley

Eleftherios Protopappas

Lead Practice Nurse 

For and on behalf of Holly Tree Surgery