Annual Infection Control Statement – Cavell House

Organisation Name: Integrum Care Group
Location: Cavell House
Registered Manager: Amanda Clarke
Infection Control Lead at the Organisation: Jade Ramshaw
Period Reviewed: January 2026 – June 2026
Date of Next Review: 30th June 2027

Introduction: 

This Annual statement has been drawn up on 26th June 2026 in accordance with the requirement of the Health and Social Care Act 2008: code of practice on the prevention and control of infections and related guidance for Cavell House. It summarises:

  1. Infection transmission incidents and actions taken.
  2. IPC audits undertaken and subsequent actions implemented.
  3. Risk assessments undertaken and any actions taken for prevention and control of infection.
  4. Staff training.
  5. Review and update of IPC policies, procedures and guidelines.

Infection Transmission Incidents: 

There were no incidents of infection transmission reported or identified during the review period.

While no transmission events occurred, the following proactive measures were maintained to ensure patient and staff safety:

  • Standard Infection Control Precautions: All staff consistently adhered to standard guidelines for hand hygiene, personal protective equipment (PPE) usage, and safe environmental decontamination.
  • Audits and Training: Regular environmental cleanliness audits and mandatory infection prevention and control (IPC) training ensured staff competency remained high.

IPC Audits and Actions:

Our Infection Prevention and Control audit programme is a structured, multi-layered framework designed to guarantee continuous compliance, identify risks early, and maintain the highest standards of clinical safety and environmental hygiene:

Daily Environmental Maintenance: Domestic staff execute daily routine cleans alongside targeted daily deep cleans of all personal and communal areas to consistently minimise the presence of germs and risk of contamination. 

Monthly IPC Audits: A monthly IPC audit is conducted by the IPC lead, focusing on high-risk compliance areas to capture performance drift and to pick up on and correct any issues between major reviews.

Quarterly Full IPC Audits: A comprehensive, systemic audit is carried out every Quarter by the IPC lead. This deep-dive evaluation covers environmental cleanliness, equipment decontamination and full regulatory compliance.

Dedicated Leadership: Our programme is driven on the ground by a trained IPC Lead who provides real-time coaching, oversees routine compliance, and bridges the gap between policy and daily practice.

Risk Assessments:

Risk assessments are carried out so that best practice can be established and then followed.

Risk assessments are reviewed regularly.

Use of and exposure to hazardous substances (COSHH): We have completed a reviewed risk assessment for the use and exposure to hazardous substances (COSHH) across our care homes. This review ensures we safely handle and store all potentially harmful materials, including clinical chemicals, heavy-duty cleaning products, and specialized medical treatments. All substances used in the home have COSHH safety data sheet and a risk assessment complete.

Cleaning specifications, frequencies and cleanliness:  We have a Housekeeping Management policy which the domestic staff work to. Monthly equipment clean schedules and daily general and deep cleaning schedules.

All ducts and extractors are professionally cleaned in line with recommended timelines and this is managed by an external company.

Training: 

New staff complete virtual training through ‘Myako’ and induction currently covers some but not all parts of Infection Prevention Control.

Refreshers are delivered through our dedicated digital learning platform. This platform tracks compliance, alerts management to upcoming renewal dates, and provides interactive, scenario-based learning modules.

Senior staff perform spot-checks across all shifts. These checks monitor that staff are adhering to Bare Below the Elbows policies and using PPE correctly at the point of care.

Senior staff conduct comprehensive, formal observations of care routines, specifically focusing on personal care delivery and mealtime experience. These are carried out to monitor IPC practices alongside general nutritional and personal care delivery.

Review and Update of Policies, Procedures and Guidance:

All policies, procedures and guidance at the service are part of the QCS management system and are updated based on their individual review schedule or more frequently if required. A review date, next review date and summary of any changes can be found on all policies and procedures to ensure oversight of the review system.

We use a robust communication and operational framework to ensure that policy changes successfully translate into daily practice in the way of staff handovers, daily communication meetings with all heads of departments, spot-checks and full care delivery observations are updated to include any new changes to be monitored.

Additional Information:

We will continue to carry out regular audits and observations to capture good evidence of infection control protocols being adhered too.

Quality Improvement Plan

Issue: We recognise that the current induction process does not thoroughly reflect infection control in practice and mainly only through online training.

Action: All new employees to undergo a mandatory infection prevention and control induction process before commencing direct duties. This initial training will provide a baseline understanding of standard infection control precautions. This is to be created and added to the current induction process.

Timeframe: One Month

Issue: IPC Champion

Action: IPC lead Jade will be completing training to become an IPC champion.

Timeframe: September 2026

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