Martlesham Heath Surgery

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

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 people were protected from abuse and avoidable harm.

There was a culture of learning from safety events and when things went wrong, staff acted to ensure people remained safe. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. Recruitment checks were carried out in accordance with regulations and new staff received an induction to their work. There were enough staff with the right skills, qualifications and experience. Staff received probationary reviews and appraisals. There was oversight of the work of clinical staff working in extended roles and the provider acted to strengthen their process with improved documentation. Staff managed medicines well and involved people in planning any changes.

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 had a 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.

We received no specific feedback from people regarding their experiences for this quality statement. Representatives from the Patient Participation Group (PPG) told us the practice leaders took concerns seriously and gave examples of when improvements to the service had been made.

There were processes for staff to report incidents, near misses, safety events and complaints. Systems were in place to record and investigate these events, identify what went well, what could have been done better, identify learning, and make any improvements required. Learning was shared with staff, as appropriate during meetings, and minutes were available. Managers encouraged staff to raise concerns when things went wrong, and managers and staff apologised and gave people support.

All staff told us they knew how to identify, and report concerns and were informed of learning as a result. Staff gave examples of improvements made following incidents and complaints, that improved care for others.For example, ensuring people being given a cancer result were seen face to face. Practice leaders also shared an example of learning, when a new process had been used to message people about blood monitoring tests and medication reviews. They acknowledged communication with people and staff, and planning time for the additional workload could have been better.

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.

People gave positive feedback in relation to the registration process, the follow up from blood tests and investigations, and timely, appropriate referrals being made.

There were systems in place for processing information for people registering at the practice, in a timely way. This included for example, homeless people and asylum seekers, refugees and other migrants.

Staff told us they had the information they needed to deliver safe care and treatment.Protocols were in place to manage the flow of work within the practice and arrangements were in place for staff to support the work of other teams, as needed. People’s correspondence which was deemed urgent, for example urgent blood results and ambulance reports were prioritised. Arrangements were in place to ensure required actions were reviewed and authorised by an appropriate clinician. Staff told us correspondence was usually dealt with the same day. We reviewed the pathology and tasks lists on the clinical system which showed they were managed in a timely way. Monthly audits of the work of non-clinical staff were undertaken by practice leaders to monitor that people’s correspondence was processed correctly and in a timely way. Any issues identified were discussed and learning undertaken.

Staff who were involved in making referrals were clear about their role and checks were in place to ensure referral requests had been actioned. A monthly audit was also completed to check people who had been referred for suspected cancer had attended their appointment and follow up arrangements were in place. The practice had fail-safe systems to ensure all cervical cytology results were received from samples sent. They also had systems to audit and follow up people who had an abnormal result and set up alerts to recall people.The service worked with other providers to deliver shared care and when people moved between services.

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

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

Staff who we received feedback from told us they were confident to report any concerns and knew who the practice safeguarding leads were. Safeguarding policies were in place and known to staff. Staff gave examples of how they supported vulnerable people, for example the paramedic undertook home visits, to people who may be at risk. All clinical and the majority of non-clinical staff had completed safeguarding children and adult training relevant to their role. Following the site visit, leaders told us staff had been advised of training which needed to be completed and given dedicated time to complete it.

The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations. Safeguarding discussions took place during monthly clinical meetings and monthly multidisciplinary meetings.We reviewed minutes of these meetings and people’s needs were discussed and reviewed, and actions agreed and followed up.

Arrangements were in place to follow up vulnerable people who had not attended for their appointment, which included for example, secondary care appointments. All safeguarding correspondence was sent by task to the clinical group, for review and action as appropriate. The clinical group included GPs and the Advanced Nurse Practitioner and was usually managed by the duty clinician, but enabled other clinicians to see and action these tasks, for example, in the case of clinician absence.

We received positive feedback from partners regarding internal safeguarding arrangements and the practice safeguarding administrator lead being responsive and engaged.

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.

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

There were effective arrangements for supporting people to identify, mitigate and manage risks. The practice had guidance for staff to identify, assess and manage people whose health was deteriorating, and for managing medical emergencies. All staff told us they could recognise people whose health was deteriorating and knew of action to take. This included immediate advice to give people and how to escalate risk to an appropriate clinician. The practice had a duty clinician every day who was available for advice and support as necessary. The majority of staff had completed sepsis or sepsis awareness training, relevant to their role. Following the site visit, leaders told us staff had been advised of training which needed to be completed and given dedicated time to complete it. The majority of staff had completed basic life support and anaphylaxis training relevant to their role and for those who had not, the practice evidenced they had booked them onto training for completion in August 2025.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Arrangements were in place to ensure the premises were maintained. Issues identified for action from risk assessments and safety checks, were shared, discussed and actions agreed with the Practice Business Manager and GP partners as appropriate. Most recommendations had been acted on, for example trained fire wardens were now in place. Where recommendations had not been completed, these were mainly due to be completed with the current building work. Ongoing checks for example, fire safety, electrical safety, and equipment calibration, were also completed. The practice had an up-to-date business continuity plan which was monitored and reviewed.

All staff we received feedback from told us there were systems, practices and processes to keep people and staff safe. The majority of staff feedback they had suitable and sufficient equipment to undertake their work and were satisfied with the health and safety arrangements in place. Staff had received fire safety training.

During the site visit, we observed fire exits were clear and fire safety equipment easily available and checked by an external company. We checked a sample of actions identified in the fire risk assessment and found they had been completed. People in the waiting room were easily visible to staff so they could identify and respond to any people whose health may be deteriorating.

The practice used technology securely and effectively and conformed to relevant digital and information security standards with arrangements in place for the confidentiality of data management. All staff had completed training in information governance. Staff gave examples of how they ensured people’s confidentiality and demonstrated they took information security seriously.

The service made sure there were enough qualified, skilled and experienced staff who received effective support, supervision and development. They worked together to provide safe care that met people’s individual needs. Feedback from people was positive in relation to the knowledge, skill, care and treatment provided by clinical staff.

Some staff told us there had been a turnover of staff over the last year. Practice leaders advised they continued to have difficulty permanently recruiting nursing staff and arrangements were in place to cover nursing work, until successful recruitment. Practice leaders had recruited Care Coordinators who were being trained and supported to become multi-skilled in a range of areas, so they worked flexibly in response to peak times of demand from people using the service, and to minimise the impact of unexpected staff absence. Some staff were new in post and had received training and support but needed time to fully embed their roles. The practice directly employed a Physician Assistant, an Advanced Nurse Practitioner and a Paramedic through Primary Care Network funding.

Safe recruitment practices were followed in line with the practice’s recruitment policy. Appropriate recruitment checks were carried out which included Disclosure and Barring (DBS) checks. The practice’s chaperone policy detailed the specific roles and responsibilities of chaperones depending on their level of DBS check. We checked a sample of records of staff who carried out chaperone duties and found they had received a disclosure and barring (DBS) check. However, 1 person had not completed chaperone training. The practice took immediate action and reviewed the training records of staff, confirmed those who had completed chaperone training and recorded a list of staff of who could chaperone which they evidenced was displayed in the practice. This information was shared with all staff.

The professional registration of clinical staff was checked at recruitment and on an ongoing basis. However, we identified 1 clinician whose registration had not been checked on an ongoing basis. The practice took immediate action and confirmed their professional registration. All new staff received an induction, adapted to their role. Staff told us they had regular appraisals and a sample of records we reviewed confirmed this.

The practice was able to demonstrate staff had the skills, knowledge, and experience to carry out their roles.Staff who were responsible for long term condition reviews, childhood immunisations and cervical screening had received training, had updated their knowledge, and their competency was checked on an ongoing basis. Arrangements were in place for the clinical oversight of staff working in extended roles, which included those who prescribed medicines. There was regular review of their practice, supported by peer review and protected time for case discussions. However, we identified this oversight was not consistently documented for all relevant staff. At the site visit, 1 of the GP partners advised they would complete the non-GP clinical consultation competency assessment oversight form on a regular basis for all relevant staff. A duty clinician was available for clinical advice and support, for example to discuss home visits and post home visit support.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Feedback from people was positive in respect of the cleanliness of the practice environment.

The practice had a lead nurse for infection, prevention and control (IPC), who had taken over this role in May 2025, following the previous IPC nurse lead leaving in March 2025. Due to recently starting in role, the IPC nurse lead had not yet completed any IPC lead training, or joined the Integrated Care Board (ICB) IPC forum meetings, although practice leaders told us they had met with the ICB and this was planned.

An internal IPC audit completed in May 2025 had an overall score of 69% compliance. The practice had an action plan in place. The practice was in the process of having building works completed to create more clinical rooms and upgrade the environment which included identified improvements to IPC arrangements.

During our on-site visit, we observed the practice to be clean and tidy. We saw documented checks of cleaning and arrangements in place to effectively communicate with the external cleaning company and resolve any issues. There were records of cleaning which included areas and equipment to clean and how to clean them. However, there were 2 systems in place, which caused some confusion. We raised this with practice leaders who advised they would review this. Appropriate arrangements were in place to manage clinical waste.

Policies and guidance were available for staff and all staff had completed training relevant to their role. Staff told us they had no concerns regarding infection, prevention and control (IPC) and told us about the systems in place for safely dealing with clinical specimens and spilt bodily fluids.

We reviewed staff immunisation records. We found the practice did not hold the relevant information relating to the immunisation status for all staff, but were in the process of gathering this. For example, some staff had been referred to occupational health and some staff had a completed risk assessment.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. We received positive feedback from people in relation to medicines management.

A small proportion of people registered with the practice were eligible to use the dispensary services at the practice. The dispensary was clean, tidy and well organised with only authorised people having access. Medicines stocks within the dispensary were secure, managed well, and expiry dates regularly checked. Standard operating procedures were in place for all the dispensary activities. A delivery service was available for those people who required it. Dispensary staff recorded incidents and near misses and these were reviewed regularly to minimise any reoccurrence. Dispensing staff had annual appraisals and competency checks. GPs undertook dispensing review of medication (DRUMs), which help identify any issues and whether any medicines were no longer required. The practice belonged to the Dispensary Services Quality Scheme (DSQS) and completed annual audits as part of this; we saw a recent audit ensuring that people requiring medicines to treat epilepsy were routinely requesting their medicines.

Patient Group Directions (PGDs) were in place to allow the nurse to give vaccinations without a prescription, and these had been appropriately authorised for use. Prescription stationery was managed appropriately. Medicines that required cold storage were being appropriately kept within temperature monitored fridges. Emergency medicines were available for use within the practice, stored appropriately and checked regularly.

Medicines records were comprehensive and included those medicines that were prescribed and supplied elsewhere. Changes made to medicines following appointments elsewhere such as the hospital, were actioned in a timely manner.

Our clinical searches showed that people received the correct monitoring when prescribed medicines by the practice. For example, we completed a clinical search for 3 different immunosuppressant medicines, and 1 search for a medicine for heart failure and found all people had received appropriate monitoring. Another search found people who were prescribed certain medicines, had been prescribed an additional medicine to help protect the stomach from ulcers or bleeding, and advised people accordingly, in line with national recommendations.

Monthly audits were completed to identify and recall people whose medicines needed additional monitoring. The duty clinician was advised of people who did not respond to invitations for a medicine review and to the additional monitoring required, and acted on this information.

There was evidence that safety alerts had been actioned, and people received the correct information about any risks associated with their medicines. We completed 2 clinical searches and found for 1 search, people had been informed of the risks and when it would be necessary to seek medical advice. For the other search the provider demonstrated people were not at risk of pregnancy and were aware of the risks of the medicine.

Medicines reviews were undertaken by the practice, and this may have included a self-review by questionnaire where appropriate. We reviewed the quality of medicines reviews and sampled 5 people’s records from 319 people who had a medication review in the last 3 months. We were satisfied with the quality of these medicine reviews. Another search identified 250 people who were prescribed 10 or more medicines and therefore required a medicines review in the previous 18 months. All people had been reviewed.

We reviewed a range of prescribing indicators, which included for example, antimicrobials, antipsychotics, hypnotics and antibiotics. The practice were within the expected range for prescribing these medicines.