IPC Annual Statement Report 

Posted on:

St Stephen’s Medical Partnership  

28th November 2025 

Purpose   

This annual statement will be generated each year in November 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. The report will be published on the practice website and will include the following summary:  

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

Infection Prevention and Control (IPC) lead  

The leads for infection prevention and control at St Stephen’s Medical Partnership are Practice Nurses Donna Keen and Lynda Lewis supported by Jodie Denton, CQC and IG Lead.    

a. Infection transmission incidents (significant events)  

Significant events involve examples of good practice as well as challenging events. 

Positive events are discussed at meetings to allow all staff to be appraised of areas of best practice. 

Negative events are managed by the staff member who either identified or was advised of any potential shortcoming. This person will complete a Significant Event Analysis (SEA) form that commences an investigation process to establish what can be learnt and to indicate changes that might lead to future improvements. 

All significant events are reviewed and discussed at several meetings each month. Any learning points are cascaded to all relevant staff where an action plan, including audits or policy review, may follow.  

In the past year there have been one significant event raised that related to infection control. There have been no complaints made regarding cleanliness or infection control.   

b. Infection prevention audit and actions  

St Stephen’s Medical Partnership comprises of two sites: St Stephen’s Surgery, Adelaide Street, Redditch, B97 4AL and Maple View Medical Practice, Tanhouse Lane, Churchill Centre, Redditch B98 9AA. The combined list of patients is currently 17,360. 

All staff are required to complete mandatory infection control training and clinical staff are to complete sharps injuries training every two years. All staff are required to complete Waste Management training every 36 months. This training is on Clarity Team Net and reviews of mandatory training take place during appraisals. Legionella training is also available to those with responsibility for carrying out routine checks. 

The newly introduced Infection Prevention and Control Handbook was updated July 2025. Legionella Policy was updated October 2025. Legionella Procedure and Logs of checks are available too. 

Cleaning schedules are displayed throughout both practices. 

The following audits have been carried out: 

05/04/24 Pre-Acceptance Waste Audit St Stephen’s Surgery valid until 2029 

22/05/24 Pre-Acceptance Waste Audit Maple View Medical Centre 

valid until 2029 

16/04/25 Minor Surgery Infection Prevention Audit Maple View Medical Centre 

& St Stephen’s Surgery 

18/06/2025 CQC Harmony Cleaning of practice audit Maple View Medical Centre 

& St Stephen’s Surgery 

17/10/2025 IPC mini audit St Stephen’s Surgery 

05/11/2025 IPC mini audit Maple View Medical Centre 

25/11/2025 Infection Control Audit Maple View Medical Centre 

25/11/2025 Cold chain audit  

27/11/2025 Infection Control Audit St Stephen’s Surgery 

c. Risk assessments   

Risk assessments are carried out so that any risk is minimised to be as low as reasonably practicable. Additionally, a risk assessment that can identify best practice can be established and then followed. 

The following risk assessments were carried out/reviewed:  

04/06/24 Legionella Risk Assessment Maple View Medical Centre 

20/11/24 Legionella Risk Assessment St Stephen’s surgery 

29/08/25 COSHH Risk Assessments both sites 

06/12/2024 Clinical waste handling risk assessment  

New and expectant mothers are risk assessed. 

Young persons are risk assessment.  

Staff with medical conditions are risk assessed. 

All new members of patient facing staff are referred to occupational health and offered vaccinations. 

All staff are offered flu and covid vaccinations in-house. 

In the next year, the following risk assessments will be reviewed annually:  

Legionella 

COSHH 

d. Training  

In addition to staff being involved in risk assessments and significant events, at St Stephen’s Medical Partnership all staff and contractors receive IPC induction training on commencing their post. Thereafter, all staff receive refresher training biannually. 

e. Policies and procedures 

The infection prevention and control related policies and procedures that have been written, updated, or reviewed in the last year include, but are not limited, to:  

  • Assistance dogs and other animals’ policy 
  • Cleaning standards and schedule policy 
  • Cold chain policy 
  • Competency Frameworks 
  • COSHH guidance 
  • Guidance: Report a notifiable disease 
  • Health, safety and risk management handbook 
  • Induction book 
  • Infection prevention and control handbook 
  • Legionella policy and procedures 
  • Mandatory recommended training policy 
  • Needlestick injury protocol 
  • New and expectant mothers’ policy 
  • Pandemic management and staffing policy 
  • Patient isolation protocol 
  • PPE policy 
  • Sepsis guidance 
  • Staff immunisation policy 
  • Waste management policy 
  • Waste Management policy 

Policies relating to infection prevention and control are available to all staff and are reviewed and updated annually. Additionally, all policies are amended on an ongoing basis as per current advice, guidance, and legislation changes.   

f. Responsibility 

It is the responsibility of all staff members at St Stephen’s Medical Partnershipto be familiar with this statement and their roles and responsibilities under it.   

g. Review  

The IPC leads are responsible for reviewing and producing the annual statement.  

This annual statement will be updated on or before 30th November 2025 

Signed by  

J. Denton 

Jodie Denton 

For and on behalf of St Stephen’s Medical Partnership