Martlesham Heath Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This is the first assessment for this service due to the legal entity change of this provider. This key question has been rated as good. We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support.

People were involved in assessments of their needs, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools. Staff regularly reviewed people’s care and treatment. Staff, teams and services worked together to improve people’s outcomes and support people whose circumstances may make them vulnerable. Staff made sure people understood their care and treatment to enable them to give informed consent. Where people did not have capacity, staff involved people who were important to them, and took decisions in people’s best interests. Staff supported people to live healthy lives and where possible, reduce their future need for care and support.

This service scored 75 (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 made sure people’s care and treatment was effective by assessing their health, care, wellbeing and communication needs with them.

People gave positive feedback in relation to how their needs were assessed by clinicians. Staff told us people were involved in any assessment of their needs, which included their carers, as appropriate. Systems were in place to identify people with caring responsibilities at registration, opportunistically, and through self-reporting. They held a carers’ registerand 4.4% of the practice population were registered as carers. The practice had a Carers’ Champion who supported people who were carers, as needed, for example by signposting to Suffolk Family Carers.

Staff used digital flags within people’s care records to highlight any reasonable adjustments needed for health and care access. This information was gathered at the point of registration and opportunistically. Staff shared examples, such as the requirement for an interpreter and people with a hearing difficulty being booked into face to face rather than a telephone appointment.Staff checked people’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing.

The practice had systems to identify and prioritise care and treatment for people who were vulnerable. For example, all people with a learning disability had been invited for a learning disability health check and 86% of these people had received a learning disability health check in the previous 12 months. Reasonable adjustments were in place to support people’s attendance. Arrangements were in place to invite and complete NHS health checks for people who were eligible, and health checks for people aged over 75 years were also available.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. People were recalled for reviews, for example, for a long-term condition review and follow up arrangements were in place for people who did not respond to invitations. Arrangements were in place to coordinate any tests required for people with long-term conditions, so results were available at the time of their review appointment. People with multiple long-term conditions were reviewed during 1 longer appointment. People gave positive feedback in relation to the clinical care and treatment they received.

Staff told us that the leaders provided opportunities for them to keep up to date with current guidelines, and changes to evidence-based care and treatment, for example through training days, clinical meetings and learning from clinical audits. The practice monitored and improved outcomes for people by carrying out clinical audits.

We observed from the clinical searches the service delivered evidence-based care. For example, there were effective systems for monitoring people with chronic kidney disease stages 4 or 5, people with hypothyroidism, and for identifying, monitoring and reviewing people with a potential missed diagnosis of diabetes.

One search identified out of 366 people with diabetes, 30 people had a blood result which was above the recommended level. We reviewed a sample of 5 people. People had received monitoring, and the practice demonstrated they worked to engage with people who found compliance difficult.

Another clinical search identified the practice had 610 people on their asthma register, of which 13 people had been prescribed 2 or more courses of rescue steroids within the last 12 months. We reviewed the records of 5 people and found people with asthma who were prescribed emergency steroids were not consistently followed up to check their response to treatment in an appropriate timeframe. We raised this with the provider who took action to address this so people were consistently followed up in a timely way.

The service worked well across teams and services to support people. They shared assessments of people’s needs when they moved between different services.

People who provided feedback for this assessment had no specific views or concerns in this area.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, for example for people with palliative care and end of life needs. Some care coordinators were trained to cover reception, prescriptions and medical secretary roles. Some staff told us clinicians and managers supported reception at busy times by helping with phone calls and queries from people. Arrangements were in place for some staff from this practice and another nearby practice, with the same management team, to work across both sites so they could respond to the needs of people in a flexible way.

Partners we received feedback from had no concerns regarding how the service worked together with other services.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

People who provided feedback for this assessment had no specific views or concerns in this area.

Staff focused on identifying risks to people’s health, including those in the last 12 months of their lives, people at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, which including stopping smoking and tackling obesity. NHS health checks were offered to people aged 40 to 74 years. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. Staff gave examples of where people had been positively supported to live healthier lives, which included healthy eating and weight management. The practice had a self-testing blood pressure machine in the waiting room. People were advised to share their results with staff at reception and arrangements were in place for results to be reviewed by a clinician if necessary.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves. From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. People gave positive feedback in relation to the clinical care and treatment they received.

The practice was above the England average for breast screening and bowel cancer screening coverage. They had achieved the World Health Organisation target of 95% for 4 of the childhood immunisation indicators and met the minimum target of 90% for the fifth indicator. Practice staff had worked to improve the uptake of cervical screening. NHS Digital data to the period 30 June 2024 found cervical screening uptake in the 50 to 64 age range to be above the 80% target at 84.4% and in the 25 to 49 age range to be below the 80% target, at 77.6%.

The practice demonstrated they had an effective recall system in place and strategies to educate and encourage attendance for childhood immunisation and cervical screening. Discussions were held opportunistically, and prompts for discussion were given for example, during post-natal appointments. Appointments were available during the day on a Wednesday or Thursday, with extended hours appointments available until 8.30pm on 1 weekday at a nearby GP practice. People could book an appointment online, by telephone or in person, to discuss any concerns they had. Arrangements were in place to follow up people when they did not respond to an invitation or attend their appointment. Examples were given of successful reasonable adjustments made to support people to attend, for example, visits to meet the nurse, show the equipment involved and explain what would happen.

Staff told people about their rights regarding consent and respected these when delivering person-centred care and treatment. People’s feedback demonstrated they felt at ease during consultations, were listened to and procedures were explained well. People were appropriately informed when making care and treatment decisions.

The practice had systems and processes in place to obtain consent to care and treatment in line with legislation and guidance. There were policies in place to support staff when obtaining consent from adults, children and people who lacked mental capacity.

Staff we spoke with had a good understanding of consent and the majority of staff had completed training on consent and the Mental Capacity Act. Some staff had not completed this as it had not been included on their mandatory training list. The practice took immediate action and added this to their required training. Clinicians supported people to make decisions, and where appropriate, they assessed and recorded a person’s mental capacity to make a decision. Clinicians told us they always obtained consent from people which was recorded on the clinical system. Chaperone posters were displayed in the practice informing people this was available to them, and information was available on the practice website.