Wyke Regis and Lanehouse Medical 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection, we rated this key question as Requires Improvement. At this assessment, the rating has remained the same.

The service was in breach of legal regulation in relation to Safe care and treatment and Fit and proper persons employed. We identified the practice did not have fully effective processes to ensure actions had been taken in response to identified health and safety risks. This included shortfalls in relation to the premises, equipment and infection prevention and control procedures. The practice had plans to reinstate documented ongoing clinical supervision led by named clinical supervisors, to ensure staff were supported to carry out their roles safely, but these had not yet been embedded.

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.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff were encouraged to raise concerns when things went wrong. They told us that significant events, complaints and examples of patient feedback were shared and discussed during regular all-staff meetings. Staff felt there was an open culture and understood their duty to raise concerns and report incidents. Leaders provided examples of how incidents were investigated and resolved.

There were policies and processes in place to record, investigate and take action from incidents and complaints. These were discussed in monthly governance meetings and minutes made available to staff who were unable to attend. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support in line with the duty of candour. Learning from incidents and complaints resulted in changes that improved care for patients.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way. Policies and guidance were in place to support workflow and pathways for appointments, referrals, records and correspondence. The practice had a system in place for processing new information and summarisation of notes.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

There were designated safeguarding children and adult leads at the practice. There were monthly multi-disciplinary meetings where safeguarding issues were discussed and these were attended by clinical staff and practice management staff. External stakeholders were invited to safeguarding meetings where relevant, such as community mental health teams. Systems were in place to appropriately refer people to the local authorities and information was shared amongst community teams where required. Safeguarding and chaperoning policies were in place and accessible to staff.

A mixture of clinical and non-clinical staff members had chaperone responsibilities as part of their role. Those staff members had completed Disclosure and Barring Service (DBS) checks to ensure they would be appropriate to undertake this role.

We reviewed a sample of patient records as part of our remote clinical searches and found care plans noted how people were to be supported to remain safe. There were safe systems and processes in place to ensure children had been appropriately followed up with when they failed to attend appointments.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The practice had maintained emergency equipment and staff were aware of procedures including recognising a deteriorating patient and were trained on relevant actions to take. Patients were advised on risks related to their condition and actions to take if their condition worsened.

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. The practice had carried out a fire risk assessment across all practice sites in April 2025 and were in the process of completing the identified remedial actions to an agreed deadline. At the time of inspection, the practice had not carried out emergency lighting and fire alarm servicing in line with fire safety policy. However, the practice provided records to show the emergency lighting and fire alarm servicing assessments had been carried out after the inspection. The practice had carried out a Portable Appliance Testing (PAT) for equipment in April 2025. The practice demonstrated any failed equipment had been removed and replaced at Wyke Regis Health Centre.

There was a legionnaires risk assessment that had taken place September 2024 at the Lanehouse Medical Practice site, however, the other two sites had not had a recent legionnaires risk assessment carried out in line with Health and Safety Executive guidelines. The practice had put some control measures in place to reduce the risks related to legionella bacteria such as water temperature testing across all sites. The practice water temperature testing records showed in some rooms the water temperature was outside of the safe temperature range, increasing the likelihood for legionella to grow. No action had been taken between January and July 2025 to adjust water temperatures to prevent the risk of legionella infection. The Health and Safety Executive guidance recommends maintaining hot water above 50 degrees Celsius and cold water below 20 degrees Celsius.

During our on-site visit at Wyke Regis Health Centre, there were 2 patient examination couches that were unable to be altered in height. We noted these consultation rooms were being used by clinical staff on the day of our on-site visit. Therefore, there was a risk of poor staff ergonomical working and lack of manual handling considerations and reasonable adjustments for health and safety of staff members as well as patients potentially not able to receive effective examinations. The practice had not considered these risks in the form of a risk assessment nor was this documented on the practice risk register. However, there was a business continuity plan in place which was monitored and reviewed.

The service did not always make sure staff received effective support, supervision and development.

Staff could discuss clinical queries in relation to their medicine prescribing or care and treatment planning with leaders who they said had an ‘open door’ policy. We noted there were daily slots available for clinicians to seek support with the on the day duty GP. Although the practice had carried out annual audits of patient consultations and records by clinical staff members, we reviewed all 3 non-medical prescribers records and while these included prescribing checks and qualitative notes checks to ensure overall quality of care was being provided, the practice had not ensured clinical staff had access to ongoing supervision through a named supervisor as outlined within the practice’s clinical supervision policy. The provider failed to ensure there was regular documented clinical supervision in line with practice policy, in order to discuss and feedback care and treatment in line with evidence-based practice. However, this had taken place historically prior to January 2025. Staff told us the clinical supervision role had not been reallocated since the departure of one of the practice’s salaried GP’s, who had been responsible for the completion of clinical supervision.

Staff received a formal induction relevant to their role and responsibilities and were supported through ongoing appraisals.

All recruitment and Human Resource (HR) records were not always kept in-line with practice policy and the Schedule 3 requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We carried out a review of the provider’s recruitment checks in relation to 4 members of staff and information was not always available and up to date in line with practice policy. This included photographic identification of staff members and curriculum vitae (CV) to ensure staff had the relevant experience and to identify any gaps in employment. The practice had plans to transfer its HR records to a new electronic governance system, which would include updating recruitment processes and responsibilities. This had not yet been initiated at the time of inspection.

Staff told us they felt there were not enough staff to manage workloads of activity. However, it was noted rotas were completed with oversight of cover where required, so that should a clinician be absent at short notice, their pre-booked appointments could be put into protected available same day slots with another clinician or remote support offered. Some non-clinical staff told us they would often cover other team members responsibilities which placed additional pressure in their roles which was often not recognised. However, the practice had imminent plans to recruit an additional administrative staff member to assist with reception duties. There were staffing arrangements to ensure in the event of emergency, the risk of unsafe practice was mitigated to prevent lone working.

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

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place. However, we observed the premises to be visibly unclean in places during our on-site visit. For example, some of the clinical and non-clinical rooms had debris on floors, dust on medical equipment and windowsills, despite being told the cleaner carried out checks routinely.

Risk assessments and audits were completed, however, the practice failed to identify shortfalls in performance and risks relating to poor infection control, indicating a lack of effective monitoring of infection prevention and control national guidelines. For example, we found dirty cleaning equipment, inconsistent and unclear arrangements for mop disposal, and insecure and unlocked clinical waste storage which posed a risk to public misuse. The practice had not identified clinical waste storage arrangements were not in line with national guidelines. For example, not all of the clinical waste storage bins were locked at Wyke Regis Health Centre. None of the clinical waste bins had been stored securely and chained to prevent public misuse. Clinical waste had not been labelled with appropriate practice details in line with national guidance.

We observed improper storage for patient examination couch rolls in patient consultation and treatment rooms, which were not kept in line with infection control national standards. The practice had not retained and stored all Control of Substances Hazardous to Health (COSSH) risk assessments for all of the infection control products stocked, alongside Safety Data Sheets (SDS) which the practice had retained. This posed a health and safety risk for staff without guidance of usage and what to do in the case of incidents, in particular, to evaluate the specific risks associated with how that substance is used in the workplace. The practice was unable to provide a risk assessment and inclusion for cleaning carpets in other communal areas including; how often they are cleaned and what actions would be taken if carpets are contaminated with body fluids or spillages within the practice’s Infection prevention and control (IPC) policy, in line with the national standards of healthcare cleanliness 2025.

The service made sure medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

During our remote clinical searches, we identified patients who had been prescribed high-risk medicines had been appropriately monitored and reviewed in line with national guidelines.

There was effective oversight to ensure patients received timely medication reviews from our clinical searches. A randomised examination of medication reviews determined that records contained qualitative information to inform future care planning which demonstrated improvements had been since the last inspection.

During our on-site visit we found Patient Group Directions (PGD) and Patient Specific Directions (PSD) were in place which relevant staff worked to. Prescription stationery was logged and stored securely.

Medicines were stored securely and the practice held appropriate emergency equipment and emergency medicines. The practice maintained appropriate fridge temperature records where vaccines were being stored and observation of variances of temperature had been addressed and logged.

Leaders were able to demonstrate that there was an effective system to ensure safety alerts were acted upon in a safe way to patients. During our clinical searches, we found patients who were affected by medicine safety alerts were contacted to inform them on the risks and prescriptions were reviewed appropriately. This was an improvement since our last inspection.