Wyke Regis and Lanehouse Medical Practice

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led - We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment, we rated this key question Good. At this assessment, the rating has changed to Requires Improvement.

The service was in breach of the legal regulations relating to good governance and failure to notify the commission of registration changes relating to the legal partnership and when a registered person ceases to carry on or manage the regulated activity. We found the practice’s governance systems had not identified or effectively monitored compliance and implemented actions advised within health and safety, fire safety and legionnaires risk assessments or audits carried out by the practice, such as infection prevention and control in line with practice policy.

This service scored 57 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, inclusion, and engagement.

CQC received 11 staff feedback surveys during the inspection. Of those 11 staff, 7 highlighted there was an unclear and lack of understanding of vision for the future and values. Although the practice had an improvement plan in place which was reviewed regularly, staff were not always involved in the development of the structure and provision of the service. The practice did not have a documented and visible mission statement that was inclusive of staff and service users. However, after the inspection, the practice had implemented this on the practice website and was visible within the premises. Examples of staff dissatisfaction were also received regarding a lack of clear communication to ensure roles and duties were clear. For example, there were no embedded arrangements to support staff in their roles and to ensure responsibilities were reallocated and managed for those who were no longer working at the service. However, staff told us there was a positive team culture within the practice clinical team and they felt encouraged to take accountability to manage day to day workload, including involvement in clinical education sessions and continuous professional development.

There were not always clear, established and effective systems and processes in place for leaders to share their vision, experience and support with colleagues. Although the provider was able to support the practice team remotely, there were often delays in requests to review practice procedures affecting service provision, such as requests for the replacement of equipment or factors affecting the health and safety of people and the premises.

Leaders did not always recognise the impact in which the service delivered care, treatment and support. Staff feedback surveys received by CQC during the inspection highlighted there was an unclear and lack of understanding of the provider and a disparity of how the practice operated at a local level, including unrealistic workload to carry out tasks relating to the management of patient care. We noted examples of staff dissatisfaction with employment disputes and unclear communication and support from senior leaders relating to human resources. Despite this, the provider had demonstrated oversight of clinical performance to workload and activity through risk rated parameters which were reviewed daily, such as tasks relating to outstanding patient results, referrals, medication reviews and triage requests. Remote support was offered to accommodate determined risk to these areas or where possible locum clinical staff cover.

The practice had established Freedom to Speak up arrangements in place as well as a whistleblowing policy.

Staff highlighted although feedback and concerns could be raised, they were not always confident these would be addressed and communicated with demonstratable service changes. There were opportunities for staff to raise feedback about the service through a recent staff feedback survey. The practice had oversight of themes and trends including positive outcomes for people and the service, including staff being treated equally. Where constructive feedback trends were identified, leaders told us there were plans in place to review staff wellbeing and these areas were placed on the practice’s improvement plan. The practice had implemented additional mechanisms to support staff such as a staff forum for raising feedback and concerns informally as well as extra communication channels to share service changes, learning and celebrating positive feedback via weekly staff newsletters.

We reviewed the practice’s incident management systems and processes, which demonstrated when something went wrong, people received an honest and timely apology and were told about any actions being taken to prevent the same happening again.

Staff were offered an employee assistance program (EAP) and the practice had access to occupational health services where required.

There was a zero-tolerance policy in relation to the abuse of staff with mechanisms in place to protect people and minimise the likelihood of reoccurrence.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality for people who work for them. Policies and procedures to promote diversity and equality were in place. Mechanisms were in place to address concerns relating to discrimination. Adjustments had been made to ensure all staff were valued, for example we saw reasonable adjustments to support the risks posed to the health and safety of staff who were pregnant while working.

The service did not have effective systems and processes to support good governance. They did not act on information about risk or share this securely with others when appropriate.

Risks were not always effectively identified, assessed, and mitigated in areas relating to health and safety, fire safety, legionnaires and infection prevention and control. Internal quality monitoring systems had also not identified the requirement for remedial actions to be taken to ensure people were kept safe. The provider’s governance systems had also not identified the legal requirements to notify CQC of the registration changes of the service. In particular, changes made to the Registered Manager and partners had occurred in 2023 but were still not correct before CQC prompted an update was required in May 2025. This was still not completed by the time of the on-site visit, but the provider was able to demonstrate attempts were being made.

However, staff had access to policies and procedures and attended regular meetings about the practice, including the management of patient care.

Leaders told us about the ways in which they monitored complaints, incidents and significant events. The records we reviewed identified the practice had investigated these appropriately and staff understood how to apply the duty of candour where applicable in line with practice policy timeframes. However, processes to record the corresponding complaints investigation outcomes were not always effective. For example, the practice had not included complaints reference identification numbers and records were not stored systematically to ensure the appropriate oversight was in place.

Information was stored securely in line with digital security standards with relevant information made available for patients to access in line with privacy, consent notices and general data protection regulations. This included how patient data was used, choices regarding consent and how to protect online data through notices within the practice, registration forms or online via the practice website.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners including community teams and external stakeholder healthcare providers.

The provider worked with other practices within their primary care network to offer extended access appointments, such as for cervical screening, leg ulcer clinics and vaccination programmes. Staff had made adjustments to improve the coordination of their service with community healthcare services, including through established multi-disciplinary team meetings centred on the care of those at higher risk of hospital admission as well as frail and vulnerable patients.

Staff told us they had strong relationships with healthcare professionals within the local community to support care provision and joined-up care. Staff spoke positively about the work that was happening in the local community such as neighbourhood integrated teams, and were proud to have made an impact. Feedback from community providers highlighted positive experience working with the practice in conjunction with the primary care network, including a collaborated approach to monitoring and providing care and treatment for patient’s needs, such as patients with poor mental health and for end-of-life care.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering positive outcomes and experiences for people.

The practice had a program of quality improvement audit activity and routinely reviewed the effectiveness and appropriateness of the care provided. For example, there was a clear plan for conducting clinical and non-clinical audits. Outcomes and learning were shared with staff to ensure future best practices were implemented.