Hadwen Health Infection Control Annual Statement 2025
Purpose
This Annual Infection Prevention and Control (IPC) Statement is produced in accordance with 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:
- Any infection transmission incidents and actions taken (reported in line with the Significant Event procedure).
- Infection prevention and control audits undertaken and associated actions.
- Risk assessments carried out for the prevention and control of infection.
- Staff training undertaken.
- Reviews and updates of IPC policies, procedures and guidelines.
Infection Prevention and Control (IPC) Lead
Hadwen Health has one Lead for Infection Prevention and Control: Sharon Hargreaves, Lead Nurse.
The IPC Lead is supported by: Claire Hammett (Administrator/Facilities).
Infection Transmission Incidents (Significant Events)
Significant events, including both examples of good practice and challenging incidents, are investigated thoroughly to identify learning and opportunities for improvement. All significant events are reviewed at monthly meetings, with learning cascaded to relevant staff.
During the past year, Hadwen Health has had no significant events relating to infection control. There have also been no complaints regarding cleanliness or infection prevention and control.
Additional advice was sought from NHS Gloucestershire ICB Infection Prevention and Control Lead regarding the frequency of privacy curtain changes. Cleaning specifications confirm that curtains should be cleaned, or disposable curtains replaced, every 12 months. Hadwen Health uses disposable curtains and ensures they are replaced annually, or sooner if visibly soiled.
Although modesty curtains are handled by clinicians, they are not handled by patients. Clinicians have been reminded to remove gloves and perform hand hygiene following examinations and prior to handling curtains. Curtain condition is reviewed regularly.
Infection Prevention Audits and Actions
The Annual Infection Prevention and Control Audit was completed by Sharon Hargreaves on 08/12/2025. A target score of 80% was set, and an overall score of 97% was achieved.
Audit Breakdown
- General IPC compliance: 100%
- Environment compliance: 91%
- Hand hygiene and PPE compliance: 97%
- Domestic cleaning cupboard compliance: 94%
- Clinical compliance: 100%
- Sharps compliance: 100%
- Waste compliance: 100%
- Vaccine compliance: 96%
The audit demonstrated strong compliance across all areas. To further improve standards, the following actions have been identified:
- Review notice boards in all rooms and laminate posters where required.
- Wall-mount gloves where appropriate.
- Review equipment storage in clinical rooms.
Additional Audits Completed During 2025
| Audit Conducted | Result |
| Hand hygiene audit | 89% |
| Domestic cleaning audit | 94% |
| Clinical room audits | 93% |
| Monthly minor operations room audit | 95% |
| Sharps audit | 95% |
| Cohese Healthcare audit | 94% |
| Clinic staff self-audit | 97% |
| Minor operations & joint injections post-operative infection audit | 100% (no infections) |
| IUD/IUS post-fitting complications/infections audit | 100% |
| Equipment audit (bi-monthly) | Not scored |
All of the above audits are scheduled to be repeated during 2026.
The use of gloves and paper bed rolls has also been reviewed following guidance from the Gloucestershire ICB Infection Prevention and Control Team, with the aim of safely reducing waste and environmental impact.
Emerging Risks and Local Context
During 2025, a measles outbreak was reported in Gloucestershire. Hadwen Health has continually reviewed IPC guidance for managing suspected cases. An allocated isolation room is available, with appropriate Personal Protective Equipment (PPE) and clear guidance regarding cleaning and ventilation following consultations.
Risk Assessments
Risk assessments are undertaken to ensure best practice is established and consistently followed. During the last year, the following risk assessments were carried out or reviewed:
- Needles and sharps risk assessment.
- Legionella (water) risk assessment: The practice has conducted and reviewed its water safety risk assessment to ensure that the water supply does not pose a risk to patients, visitors or staff.
Immunisation
The practice aims to ensure all staff are up to date with Hepatitis B immunisation and are offered occupational health vaccinations relevant to their role, including MMR and seasonal influenza.
Hadwen Health participates in National Immunisation Campaigns and provides vaccinations to patients both in-house and via home visits where appropriate.
Training
Infection prevention and control training is completed annually by all staff:
- Non-clinical staff: Level 1
- Clinical staff: Level 2
- IPC Lead: Level 3 update every year (last completed 14/02/2025)
All staff receive hand hygiene training, supported by lightbox assessments as part of the hand hygiene audit. Clinical staff also complete an annual self-audit reviewing all IPC measures.
Policies
All Infection Prevention and Control-related policies are current. The most recent review was completed on 10/07/2025.
Policies are accessible to all staff and are reviewed annually, with amendments made as required in response to updated guidance, advice, or legislation. IPC policies are circulated to staff and discussed at meetings on an annual basis.
Responsibility
All staff are responsible for being familiar with this Statement and for understanding their roles and responsibilities within it.
Review Date: December 2025
Responsibility for Review: Infection Prevention and Control Lead and Practice Manager
Next Review Due: December 2026