The practice undertakes an annual infection prevention and control review.  The latest version of which can be found below;

Purpose
This annual statement will be generated each year in September in accordance with the requirements of Health and Social Care ACT 2008 Code of Practice on the prevention and controls of infections and related guidance. Our report will be published on the Practice website and will include the following.

1. Any infection transmission incidents and any action taken. These will be reported in line with our significant event polic. (Learning logs)
2. Details of any infection control audits and action plans with action undertaken.
3. Details of any risk assessments carried out.
4. Details of staff training.
5.  Details of any updated policies, procedures, and guidance.

infection Prevention and Control Leads

• Sue Belton (Healthcare Team Manager)
• Jacq Moon (Deputy Healthcare Team Manager)
• Sarah Poole (Deputy Healthcare Team Manager)

Infection Prevention and control incidents

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

Incidents are reported to Sue Belton via our Practice Manager (Hayley Wilkinson). They are then reviewed at our clinical meetings or senior management meetings. Any shared learning will be shared with the practice staff.

In the past year, there have been no significant events relating to infection control. There have been no complaints made regarding cleanliness or infection control. We have had no outbreaks of infections.

Infection Prevention audit and action

Our last practice audit was carried out by Sue Bagshaw from the infection Prevention & Control Team on 4th August 2022 which resulted in us being scored at 96.25% and the list of action is below:

1. Repainting required to damaged walls
2. Sharps bin temporary mechanism not in place in some sharps bins
3. Some dust to high rails above couch curtains, and ventilation grill.
4. One box of dressings found to be out of date
5. Baby changing mat stained
6. Debris in mop bucket

All of the above actions have all been completed. We aim to carry out another audit 2024.

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:

1. Legionella (Water) Risk Assessment: The University of Nottingham conducts its water safety risk assessment to ensure that the water supply does not pose a risk to paƟents, visitors or staff. Water testing is currently undertaken monthly by a member of the university team.

2. Sharps Management for clinical staff – Safe handling of sharps bins, spot checks carried out 17/08/23. Next due August 2024. These will be carried out by the IPC lead.

3. Anenta carry out annual audit of clinical waste procedures. We have passed this inspection.
Finding was that waste bins not labelled. This has since been actioned.

4. University Cleaning company standard of cleaning – Quarterly spot checks carried out by IPC Management and University cleaning company. Last carried out 20/05/24

5. Cleaning schedules completed daily/weekly by cleaning staff, clinical staff and non-clinical staff.

6. All new members of staff have an induction upon starting and conduct IPC training before seeing patients. Recently we have had 2 new members of staff join the healthcare team.
They have been updated on infection control policies and assessed on infection control in relation to aseptic technique when dealing with patients that have wounds. This is
documented in their competency booklets.

7. Protective equipment is also checked on a weekly basis to ensure that all rooms have handwashing equipment, aprons, and gloves.

In the next year the following risk assessments will be reviewed

1. Hand hygiene audit – Audit to be carried out by IPC leads Sue Belton, Sarah Poole, Jacq Moon
2. External cleaning company standards of cleaning – Audit to be carried out by Management and the University Cleaning Company
3. Clinical waste audit, correct of clinical waste bags and sharps bins – Audit will be carried out by IPC leads Sue Belton, Sarah Poole, Jacq Moon
4. Audit of IPC training for all staff – Audit to be carried out by Sarah Poole

Staff training

1. Each staff member is required to complete Infection control training for Clinical/Non-Clinical depending on their role. This is via Teamnet and it is part of our mandatory training. 100% of the healthcare team have completed their online Teamnet training.
2. Practical hand washing training using glo and tell equipment is performed every two years
3. IPC training is also available online from the Primary Care Development Centre

Policies and procedures

• All Infection Prevent and Control related policies are in date for this year. Infection Prevention policies next due for review February 2025.
• IPC guidance NHS cleaning standards 2021 – B0271-national-standards-of-healthcare-cleanliness-2021.pdf (england.nhs.uk)
• 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.
• IPC Handbook with Practice Index-Next due for review February 2025 or sooner if new guidance comes in.

Antibiotic Monitoring

At Cripps Health Centre, all clinicians play a key role in reducing antibiotic resistance by practicing antibiotic stewardship. This means not prescribing antibiotics for patients who are unlikely to suffer from bacterial Infection, while ensuring the patients who do require antibiotic treatment receive the appropriate antibiotics, at the correct dose and for the proper duration. All clinicians follow guidance from the Nottingham Area Prescribing Committee.

We have raised the standard of clinical assessment, safety netting of patients by clinical education.

We monitor our prescribing of antibiotics figures regularly internally, as does the Nottingham prescribing team.

The last antibiotic prescribing audit was carried out in February 2024 and demonstrated that clinicians were prescribing the correct length and appropriate antibiotic.

Responsibility

It is the responsibility of all staff members who work at Cripps Health Centre to be familiar with this statement and their roles and responsibilities.

Review

The IPC lead and Registered Manager are responsible for reviewing and producing the annual statement.

This annual statement will be updated on or before September 2024

The University of Nottingham health Service (UNHS) welcomes complaints. They not only ensure that people can have their concerns properly addressed but that they receive the best service to improve people’s health and care.

How do I make a complaint?

In the first instance you can telephone, write or visit the Practice Manager or you can contact the NHS England Customer contact centre:

NHS England

PO Box 16738

Redditch

B97 9PT

0300 31122 33

Email england.contactus@nhs.net

Who can make a complaint?

Anyone can make a complaint. You can complain on behalf of a child, or someone who has died. If you have another person’s permission, you can complain on their behalf.

 Is there a time limit for making a complaint?

Yes. Your complaint should be made as soon as possible (up to one year after the event).

Can I get help and support?

Yes. An organisation called POhWER can provide you with support and advocacy. You can contact POhWER by phone on 0300 020 0093 or email yourvoiceyourchoice@pohwer.net

What will happen once I make my complaint?

UNHS is committed to responding to complaints as quickly and helpfully as possible. All complaints will be acknowledged when received and investigated in a manner that is appropriate to the issues raised. We will advise you how long it may take to investigate your complaint. Where possible we will offer a range of suitable options to resolve the complaint. UNHS will take action where needed to prevent the incident from happening again.

Making a complaint will not put your care at risk or adversely affect your future care.

Is it confidential?

Your rights to confidentiality will be respected throughout the investigation. However, there may be times when we need to share information without your consent e.g. to protect children and vulnerable adults.

We may also need to share your complaint with other health professionals in order to ensure any issues raised are addressed appropriately.

If your complaint involves a number of different services such as Hospitals, Mental Health services, Social Care or community health services we will work together to resolve your complaint. To do this we will need to share information.

What if I am still not satisfied?

We aim to resolve all complaints. However, if you are not satisfied with the outcome of your complaint we will look into the matter further. If you are still not satisfied with our response you can ask the Health Service Ombudsman to investigate your case.

The address to contact is:

The Parliamentary and Health service ombudsman

Millbank Tower

Millbank

London

SW1P 4QP

0345 015 4033 

The practice complies with data protection and access to medical records legislation. Identifiable information about you will be shared with others in the following circumstances:

• To provide further medical treatment for you e.g. from district nurses and hospital services.
• To help you get other services e.g. from the social work department. This requires your consent.
• When we have a duty to others e.g. in child protection cases anonymised patient information will also be used at local and national level to help the Health Board and Government plan services e.g. for diabetic care.

If you do not wish anonymous information about you to be used in such a way, please let us know.

Reception and administration staff require access to your medical records in order to do their jobs. These members of staff are bound by the same rules of confidentiality as the medical staff.

Your Data Matters to the NHS

Information about your health and care helps us to improve your individual care, speed up diagnosis, plan your local services and research new treatments. The NHS is committed to keeping patient information safe and always being clear about how it is used.

How your data is used

Information about your individual care such as treatment and diagnoses is collected about you whenever you use health and care services. It is also used to help us and other organisations for research and planning such as research into new treatments, deciding where to put GP clinics and planning for the number of doctors and nurses in your local hospital.  It is only used in this way when there is a clear legal basis to use the information to help improve health and care for you, your family and future generations.

Wherever possible we try to use data that does not identify you, but sometimes it is necessary to use your confidential patient information.

You have a choice

You do not need to do anything if you are happy about how your information is used. If you do not want your confidential patient information to be used for research and planning, you can choose to opt out securely online or through a telephone service. You can change your mind about your choice at any time.

Will choosing this opt-out affect your care and treatment?

No, choosing to opt out will not affect how information is used to support your care and treatment. You will still be invited for screening services, such as screenings for bowel cancer.

What do you need to do?

If you are happy for your confidential patient information to be used for research and planning, you do not need to do anything.

To find out more about the benefits of data sharing, how data is protected, or to make/change your opt-out choice visit www.nhs.uk/your-nhs-data-matters

Download a copy of the patient leaflet

Consent for Audio/Video surgery 2022/23

Consent for Audio/Video surgery 2022/23

Information about the General Practitioners and the practice required for disclosure under this act can be made available to the public. All requests for such information should be made to the practice manager.

Access to Records

In accordance with the Data Protection Act 1998 and Access to Health Records Act, patients may request to see their medical records. Such requests should be made through the practice manager and may be subject to an administration charge. No information will be released without the patient consent unless we are legally obliged to do so.

All GP Practices are required to declare the mean earnings (e.g. average pay) for GP’s working to delivery NHS Services to patients at each practice.

The Average pay for GPs working in The University of Nottingham Health Service in the last financial year was £92,813 before tax and National Insurance.  This is for 2 full time GPs,  19 part time GPs and 1 locum GP who worked in the practice for more than six months.

By law, the NHS ceases to have responsibility for the medical care of patients when they leave the UK.  In addition GPs are able to provide prescriptions for the treatment of a condition that is not present and may arise while the patient is abroad.

The NHS does accept responsibility for supplying ongoing medication for temporary periods abroad of up to 3 months. However, if a person is going to be abroad for more than 3 months, then they are only entitled (at NHS expense) to a sufficient supply of regular medication in order to get to their destination, where they should the find an alternative supply of that medication.

Patients residing abroad for a period of more than 3 months are legally required to be removed from the practice list.

They will also be removed from our patient list. We will be pleased to re-register patients on their return to residence in the UK and can reassure patient that their electronic notes are kept on file for reference on your return.

Patients and relatives should not seek medication for themselves while they are abroad as this constitutes NHS fraud.

Privacy Notice – Surgery Connect Telephony System (X-On)

The University of Nottingham Health Service

Plain English explanation

This privacy notice explains about our Telephony System ‘Surgery Connect’ (X-on).

Inbound calls:  the system will notify you that all telephone calls are recorded for training and monitoring purpose.

Outbound calls will also be recorded for the same reason and this information can be found in this

notice, displayed on our website and in the surgery. We lawfully do not require your consent;

however you do have the right to terminate the call if you do not wish for the call to be recorded.

All calls made to the practice by a registered patient or from the practice to a registered patient, may

have the recording attached to the clinical record and will be stored securely on the surgery connect system. All calls made by non-registered patients will be stored securely on the surgery connect system. All data originates from the caller into the practice or the practice dialling out to the recipient.

Personal data

When a call is recorded we collect:

• a digital recording of the telephone conversation
• the telephone number of both parties (internal and external)
• Personal data revealed during a telephone call will be digitally recorded for example name

and contact details to deliver appropriate services.

• Occasionally ‘special category’ personal information may be recorded where a customer

voluntarily discloses health, religious, ethnicity or criminal information to support their

request for advice and/or services.

• Telephone call recording will be turned off, when a customer’s credit or debit card details

are given, in line with Payment Card Industry Data Security Standards (PCS DSS) and data

protection legislation including General Data Protection Regulations (‘GDPR’).

People who have access to your information will only normally have access to that which they need

to fulfil their roles.

We are required by Articles in the General Data Protection Regulations to provide you with the

information in the following 9 subsections.

• Data Controller contact details – The University of Nottingham Health Service, Cripps Health Centre, University Park, Nottingham, NG7 2QW

• Data Protection Officer contact details – Paul Couldrey of PCIG consulting Ltd. Coudrey@me.com

3)    Purpose of the processing Direct Health Care – To enable a safe two way communication between patient and Surgery.

4)    Lawful basis for processing – The processing of personal data in the delivery of direct care and for

Providers’ administrative purposes in this surgery and in support of direct care elsewhere is supported under the following Article 6 and 9 conditions of the GDPR:

Article 6(1)(e) ‘…necessary for the performance of a task carried out in the public interest or in the exercise of official authority…’.

Article 9(2)(b) ‘Carrying out of obligations under employment, social security or social protection law, or a collective agreement’

Article 9(2)(c) ‘Vital interests of a data subject who is physically or legally incapable of giving consent.’

Article 9(2)(h) ‘necessary for the purposes of preventative or occupational medicine for the assessment of the working capacity of the employee, medical diagnosis, the provision of health or social care or treatment or the management of health or social care systems and services…”

*Healthcare staff will also respect and comply with their obligations under the common law duty of confidence.

5) Recipient or categories of recipients of the processed data

Data is accessible by the Practice as the Data Controller for this information. Information may be accessed remotely by the supplier for support purposes. Making recordings available for the Practice,

patients and other data subjects may request this.

6) Rights to object

You have the right to object to some or all the information being processed under Article 21. Please contact the Data Controller or the practice. You should be aware that this is a right to raise an objection, that is not the same as having an absolute right to have your wishes granted in every circumstance.

7) Right to access and correct

You have the right to access the data that is being stored and have any inaccuracies corrected. There is no right to have accurate medical records deleted except when ordered by a court of Law.

8) Retention period

The recording data will be retained for 36 months on the Telephony System before deletion. The recording in connection to a registered patient may be attached to the medical record and therefore be subject to the Records Management code of Practice for Health and Social Care Retained until 10 years after death.

https://digital.nhs.uk/data-and-information/looking-fterinformation/data-security-and-information-governance/codesof-practice-for-handling-information-in-health-and-care/recordsmanagement-code-of-practice-for-health-and-social-care-2016

9) Right to Complain.

You have the right to complain to the Information Commissioner’s Office, you can use this link https://ico.org.uk/global/contact-us/

or calling their helpline Tel: 0303 123 1113 (local rate) or 01625 545 745

(national rate)

* “Common Law Duty of Confidentiality”, common law is not written out in one document like an Act of Parliament. It is a form of law based on previous court cases decided by judges; hence, it is also referred to as ‘judge-made’ or case law. The law is applied by reference to those previous cases, so common law is also said to be based on precedent.

The general position is that if information is given in circumstances where it is expected that a duty of confidence applies, that information cannot normally be disclosed without the information provider’s consent.

In practice, this means that all patient information, whether held on paper, computer, visually or audio recorded, or held in the memory of the professional, must not normally be disclosed without the consent of the patient. It is irrelevant how old the patient is or what the state of their mental health is; the duty still applies.

Three circumstances making disclosure of confidential information lawful are:

• where the individual to whom the information relates has consented;
• where disclosure is in the public interest; and
• where there is a legal duty to do so, for example a court order

Categories of Personal Data

• race;
• ethnic origin;
• political opinions;
• religious or philosophical beliefs;
• trade union membership;
• genetic data;
• biometric data (where this is used for identification purposes);
• health data;
• sex life; or
• sexual orientation.

Personal data can include information relating to criminal convictions and offences. This also requires a higher level of protection.

https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-dataprotection-regulation-gdpr/what-is-personal-data/what-is-personal-data/

The NHS operate a zero tolerance policy with regard to violence and abuse and the practice has the right to remove violent patients from the list with immediate effect in order to safeguard practice staff, patients and other persons. Violence in this context includes actual or threatened physical violence or verbal abuse which leads to fear for a person’s safety. In this situation we will notify the patient in writing of their removal from the list and record in the patient’s medical records the fact of the removal and the circumstances leading to it.