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Infection Control Annual Statement 2026-27
📌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:
- Sahima Khanam (CQC and Facilities Lead)
- Jahmal Salmon (Group Practice Manager)
- Maisy Binion (Group Practice Manager)
Each practice site also has designated leads responsible for conducting monthly internal infection control audits:
Church Road Health
- Definite Mabhodo-Chiweshe (Practice Nurse)
- Farzana Fakir (Health Care Assistant)
- Sahima Khanam (F4HG CQC and Facilities Lead)
Stratford Village Surgery
- Fay-Vincent Dorgan (Nurse Associate)
- Stefania Apostol (Care Coordinator)
- Felicenne Tekilazaya (Practice Nurse)
- Sahima Khanam (F4HG CQC and Facilities Lead)
Glen Road Medical Centre
- Beverley Biggs (Practice Nurse)
- Iqbal Hossain (Health Care Assistant)
- Sahima Khanam (F4HG CQC and Facilities Lead)
E7 Health
- Kalsuma Khatun (Practice Nurse)
- Rahat Rana (Health Care Assistant)
- Sahima Khanam (F4HG CQC and Facilities Lead)
As of April 2026, 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 - 6 October 2025
Incident: Practice nurse noticed the fridge temperature was out of range.
Root Cause: Staff who lived locally mention the whole area had a power cut which affected the practice.
Actions Taken: We had contacted the vaccine manufacturers, GSK and Sanofi, to confirm whether the vaccine was suitable for administration. Both companies advised that it was safe to proceed with vaccination. The patient was to be informed
Learning:
- Importance of consistent cold chain monitoring:
- Fridge temperatures must be checked daily, including weekends to prevent undetected excursions.
- Good documentation practice: Accurate and timely temperature logging helps identify issues early and supports safe decision-making.
Stratford Village Surgery - 6 August 2025
Incident: There was rust buildup at the rear bottom section of one of the clinical fridges.
Root Cause: The fridge was not properly inspected during use, which meant the rust buildup was not identified.
Actions Taken: A new fridge was ordered, and an additional fridge log was created and is being completed by the Healthcare Assistants.
Learning:
- Regularly inspect equipment for signs of wear and damage (e.g., rust) to prevent risks to safety and hygiene.
- Replace compromised equipment promptly to maintain proper storage conditions.
- Ensure routine maintenance and cleaning schedules are in place to prolong
- equipment lifespan.
- Document faults and actions taken clearly to support accountability and compliance.
- Discuss equipment issues and learning points regularly in nursing meetings to promote awareness and prevent recurrence.
Glen Road Medical Centre - 8 December 2025
Incident: A box of vaccines from the delivery was left out of the fridge at reception.
Root Cause: The admin/reception staff did not place the vaccines into the vaccine fridge immediately upon arrival.
Actions Taken: The vaccines were left out for too long and had to be discarded and reported to the vaccine manufacturer for a new order of vaccines.
Learning:
- Staff to be stored in fridge as soon as they have been delivered
- Staff to ensure they maintain the cold chain management
- staff to ensure they communicate with one another, if unable to put stock away themselves.
E7 Health
No infection control incidents were reported during this period.
🧪 Audits
A comprehensive five-year Infection Prevention and Control Audit was completed by NHS England on 7 March 2024, with the next audit scheduled for March 2029.
Infection Prevention Solutions carried out an infection control audit on 8 April 2026 as part of its routine two-year inspection cycle for all F4HG Sites. .
All sites also carry out monthly internal IPC audits.
💊 Antimicrobial Stewardship
Antimicrobial resistance (AMR) is a global issue affecting all countries and populations. The scale of this threat, and the need to control and contain it, is widely recognised.
This plan has been developed to support progress towards a 20-year vision in which AMR is effectively managed and contained.
The three key aims are:
- To reduce the need for antimicrobials and limit unintentional exposure
- To optimise the use of antimicrobials
- To invest in innovation, as well as improve supply and access
Medical Practice follows clear guidelines for prescribing and monitoring antibiotics, with regular audits carried out.
At F4HG, between 2025 and 2026, antibiotic audits were conducted on the following medications:
- Amoxicillin
- Doxycycline
- Flucloxacillin
- Phenoxymethylpenicillin
- Broad-spectrum antibiotic prescribing
⚠️ 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-19 vaccines.
- 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 review of 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 15/04/26
