Stockbridge Practice

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that staff protected people from avoidable harm and made sure care was delivered from environments that were clean and well-maintained. At our last assessment, we rated this key question as Good. At this assessment, the rating has changed to Requires Improvement.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Whilst the service was testing its water temperature monthly, records showed the temperatures did not consistently meet the required standards, with some hot and cold-water readings from different outlets outside the expected thresholds. By not ensuring water temperatures were in safe ranges, people using the service were at risk of avoidable harm, including exposure to waterborne bacteria. Although the service’s water policy stated out-of-range readings should be investigated, the service was unable to demonstrate actions had been taken when the recordings had happened. The service also could not provide maintenance records for a wheelchair available for people to use. This meant they could not demonstrate the equipment was routinely maintained and safe for use, potentially placing people at risk of harm if defects or faults were not identified and addressed promptly. Since the assessment, the provider has confirmed water temperature monitoring will be reviewed, identified issues will be assessed by an external contractor, and annual maintenance checks will be introduced for the wheelchair.

Fire safety records showed that weekly fire alarm tests, as required by the service’s policy, were not consistently completed or documented. Records demonstrated that testing had only been recorded monthly or fortnightly during the previous year. This meant leaders could not be assured that fire safety systems were being monitored effectively or that faults would be identified and addressed in a timely way. The lack of consistent oversight increased the risk of delayed detection of fire-related hazards and could place people using the service, visitors and staff at risk of harm. However, the service had contracts to ensure the premises was maintained, for example, electrical wiring, tested every 5years, was completed February 2026 and the annual calibration certificate for equipment was issued April 2026. The service had a business continuity plan, which was reviewed annually and outlined how the service should continue to operate in the event of a disruption.

Prescription stationery was stored securely and managed in line with national guidance. For example, there was a clear log of prescription stationary being audited and prescriptions were kept in a locked cupboard.

The service was accessible for all people and included space for wheelchairs and prams. Hallways and corridors were clean and tidy and free from clutter. Staff offices were secure, and access was restricted from the public.

The service did not always follow safe recruitment practices. However, they made sure there were enough qualified, skilled and experience staff. They also made sure staff received effective, support, supervision and development. They worked well together to provide safe care that met people’s individual needs.

During our onsite visit, we reviewed 3 staff records and found appropriate identity, qualification and criminal record checks had been completed. However, 1 staff member had started employment without the required professional reference in line with national legislation, and no risk assessment had been undertaken by the service to mitigate this omission. The service had instead accepted 2 references that were not related to their clinical practice. Following the onsite visit, the provider requested the reference but this could not be obtained because the employer had changed ownership and was unable to support the request. In response, the provider has since provided a completed risk assessment. The provider has since confirmed that their recruitment policy has been updated to prevent this happening again.

However, the service employed a range of clinical and non-clinical staff, including GPs, nurses and pharmacy technicians. Leaders monitored that staff completed training the service had identified as mandatory and worked within their agreed areas of competence.

Staff we spoke with confirmed they felt supported in their roles and had received appropriate annual appraisals and training for their responsibilities.

The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service was unable to provide evidence relating to its 2025 infection prevention and control (IPC) audit and hand hygiene audits for the past year during our onsite visit. The service confirmed it had not completed any IPC audits at its branch site. Records relating to cleaning arrangements were also not available, including cleaning schedules, cleaning company audits and Control of Substances Hazardous to Health (COSHH) risk assessments being available for staff. The cleaning equipment stored at the service and used by the cleaning company was not in line with national guidance. For example, the availability of colour-coded equipment to be used in specific areas to reduce the risk of cross-contamination between clinical and non-clinical areas was not appropriate for the service’s needs. The service’s annual IPC statement was overdue and dated 2025, although the Infection Control Annual Statement on its website stated this should be produced every April. The service also could not demonstrate how high-frequency touch areas were cleaned regularly, for example, the blood pressure machine in the waiting room. Despite these issues, the service was observed to be clean and tidy during our onsite visit, all appropriate hand hygiene signage were visible, handwash dispensers were full, and appropriate access to personal protective equipment were present.

Following the onsite visit, the provider submitted evidence of a hand hygiene audit which had been completed within the previous 6 months, along with cleaning audits for both sites carried out by the contracted cleaning company over the same period. The hand hygiene audit identified, from the sample of staff audited, that 3 staff were not bare below the elbows and 6 did not follow the correct hand hygiene process. Following the audit, the provider confirmed staff had completed refresher training and planned to undertake a further audit, although no timescale was given for this. The provider also provided an IPC audit undertaken at the main site on 7 May 2026. The provider confirmed that audit actions had been added to an action plan. The evidence showed that most actions had been completed; however, there were gaps in the recorded progress for some actions, such as training records for staff completing sterile hand technique training.

However, vaccine fridges were maintained within the required temperature range. Temperatures were monitored and recorded regularly, with no discrepancies identified. Staff understood the procedure to follow in the event of a temperature breach.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.