Annual Infection Control Statement – Mulberry House

Organisation Name: Integrum Care Group

Location: Mulberry House

Registered Manager: Tara Cross

Infection Control Lead at the Organisation: Lucy Rose

Period Reviewed: July 2025 – June 2026

Date of Next Review: 30th June 2027

Introduction: 

This Annual statement has been drawn up on 26^th 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 Mulberry 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 (Resident of the day) to consistently minimise the presence of germs and risk of contamination.

Monthly IPC Audits: We conduct monthly audits focusing on high-risk compliance areas (such as hand hygiene, PPE usage, infection registers & paperwork evidencing daily maintenance) to capture performance drift between major reviews.

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

Dedicated Leadership: Our programme is driven on the ground by a fully trained IPC Champion 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. The following risk assessments have been recently reviewed:

Legionella: In strict alignment with current health and safety compliance protocols and our ongoing commitment to water safety management, we have recently undertaken a comprehensive and rigorous review of our existing.

Legionella Risk Assessment. This procedural evaluation was executed to ensure that all site-specific data, environmental variables, and preventative control measures remain fully validated, accurately reflecting the operational realities of our water systems while maintaining total conformity with statutory regulatory frameworks.

Water supply disruption: How to manage infection control concerns during loss of water such as Hand Hygiene.

Cleaning specifications, frequencies and cleanliness: We have a Housekeeping Management policy which the domestic staff work to. Clinical staff complete daily cleaning of all equipment, including personal wheelchairs.

All ducts and extractors are professionally cleaned in line with recommended timelines.

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:

New automatic hand sanitiser dispensers purchased and put up around the building on all units for use by all staff, visitors and residents.

IPC Champion LR refreshed her training in April 2026.

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

We are soon changing to a dosing system for cleaning chemicals to save wastage.

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