Martlesham Heath Surgery

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

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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

Leaders were aware of the challenges of delivering safe, sustainable high-quality care and had made changes to staffing and governance systems and processes over the previous 12 months. Practice leaders recognised the need to be visible and support staff as these changes continued to be embedded, and the majority of staff felt supported, able to give feedback and said they were treated equally. Leaders had a good understanding of local population issues and the challenges and priorities for their service and involved the public, staff and external partners to sustain high quality care. There was evidence of systems and processes for learning and continuous improvement. Most governance processes which supported the safe delivery of care and used information to monitor and improve performance, were effective. However, the system for the oversight of the completion of staff training was not effective and the system for the oversight of professional registration checks needed to be strengthened. The practice had identified this and were working to make improvements.

The service was in breach of legal regulation in relation good governance.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had a vision, strategy and values. These were based on delivering excellent, high quality, compassionate person-centred care, investing in staff and business support tools, and collaboration with all partners. Practice leaders aimed to maintain a relaxed, friendly and inclusive ethos to encourage transparency and an open culture. The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges. Practice leaders understood the needs of people and their communities.

The practice had a documented mission statement, clear vision and business plan for 2024 to 2027, which prioritised high quality, safe and effective care for people. The majority of staff were aware of the vision of the practice. The business plan included areas for development; designing an online forum was planned, and introducing cloud telephony had been completed. They had acted in response to the current and future needs of people and were in the process of expanding the practice with 2 additional clinical rooms, 2 telephone consultation rooms and a training room. and improving front door access and plans for further expansion were in place. The practice also had a development plan for the current year, which included for example, continued investment in social prescribing, mental health education and support, and increasing health education and signposting. They continued to obtain people’s feedback which informed their quality improvement plan, which focused on reducing unnecessary GP appointments by better use of other clinicians or teams, increasing uptake of long-term condition reviews and further improving access for people who may be digitally excluded.

The majority of staff we spoke with and received feedback from, told us that there was a supportive, people and team focused culture, which embraced technology.

The service had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills and knowledge to lead effectively.

Leaders were aware of the challenges of delivering safe, sustainable high-quality care and had made changes to staffing for improved clinical and managerial leadership, and flexibility in staffing resource, to meet the needs of people who used the service. For example, changes had been made so newly employed staff now worked at this practice and another nearby practice, with the same management team. These changes had happened over the previous 12 months. Practice leaders had recognised the need to continue to support staff as these changes were being made and continue to be embedded. They had an open-door policy, had regular ‘check in’s’ with staff and attended meetings to obtain staff feedback. Some stafffelt recent changes had led to low morale, unsettled staff and that communication could be improved, although some of these staff members and other staff acknowledged managers had worked hard to support staff and felt things were improving.

Named staff had specific areas of responsibility and staff we received feedback from were aware of staff in lead roles. The majority of staff were clear who to contact should they need advice or want to discuss any concerns.

One of the GP Partners was the Co-Clinical Director of the Wolsey Primary Care Network (PCN). They, and the leadership team worked with the other practices in the PCN and were engaged in the development of primary care services within the local area. The practice had directly employed a Physician Assistant, an Advanced Nurse Practitioner and a Paramedic through PCN funding.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Practice leaders told us they were aware of the impact changes over the previous year had had on staff and had worked to foster an open culture where staff could speak up. The majority of staff had completed Freedom to Speak Up training. 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. Processes were in place for staff to speak up, which included Freedom to Speak up arrangements with internal and external Freedom to Speak Up Guardians.

The majority of staff we spoke with, and received feedback from, told us leaders were visible and approachable, they were able to raise concerns and were listened to. Staff gave examples, which included improving the appointment booking system. Other staff advised leaders were sometimes reluctant to act on feedback, although some felt this was improving.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There were systems and processes in place to support workforce equality, diversity and inclusion, with an emphasis on the safety and well-being of staff. This included an equality and diversity policy, and the majority of staff had completed training in equality and diversity. 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. Some staff gave examples of reasonable adjustments which were in place for staff. Leaders told us they had a team social event last Christmas and were planning a summer barbecue to support with team building.

The service had clear responsibilities and roles and systems of accountability. They acted on the best information about risk, and outcomes, and shared this securely with others when appropriate. The service had effective governance and management systems where information and data were used appropriately to monitor risk, performance and quality of care.However, the system for the oversight of the completion of training was not effective and the system for the oversight of professional registration checks needed to be strengthened.

The practice was not able to evidence that all staff had completed training deemed mandatory by the practice. They were currently streamlining their processes and merging their records, to improve oversight of the completion of training for staff who worked at this practice and another nearby practice, with the same management team. However, we noted the required training for some staff was not accurate, for example consent, which the lead for training updated immediately. We noted some gaps in completed training, for example, basic life support, learning disability and autism awareness and freedom to speak up for clinical and non-clinical staff, and chaperoning, safeguarding and sepsis awareness for non-clinical staff at the appropriate level to their role. We raised this with practice leaders who acted and following the site visit, submitted evidence to demonstrate some of the training deemed mandatory by the practice had been completed but was not documented on the oversight spreadsheet. Where they could not evidence training completion, they told us all staff had been advised of training which needed to be completed, and some training was then completed, or a date had been booked. Practice leaders continued work to improve the oversight of the completion of staff training.

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. Practice leaders had planned to further strengthen their oversight of this through an online platform they had recently started to use.

There were written policies and procedures which staff we received feedback from said were easily available for staff to use. The policies and procedures we read had version control and amendments made documented. The practice had arrangements to ensure business continuity in a range of circumstances. There were a range of assurance audits which included for example, medicines management, workflow and telephone calls. These were all documented. Managers met with staff regularly to complete appraisals and performance reviews.

Managers held a range of governance meetings with staff, during which they discussed clinical concerns, significant events, complaints and emerging risks. Managers clearly recorded any actions arising from these meetings and minutes were shared with and available to staff, as appropriate. The majority of staff told us meeting notes were available to them. Practice leaders had recently changed some of their systems for communication with staff, and for storing documentation for improved oversight. We acknowledged some staff were getting used to these changes and new systems.

We saw examples of environmentally sustainable practices in place, for example, traditional lighting had been replaced with low energy LED bulbs, and they had further initiatives planned.

The provider had submitted applications to add and remove a partner from their partnership. The provider confirmed they no longer carried on the regulated activity surgical procedures and were in the process of removing this from their registration, so we did not inspect this regulated activity.

The service understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The practice was involved in a Quality Improvement Project (QIP) to assess and reduce the use of medicines associated with dependence, withdrawal and adverse outcomes. This was in response to rising concerns about overprescribing although national figures did not indicate that the provider was prescribing higher number of prescriptions than other comparable practices. The project was split into 3 phases, 2 of which had been completed: clinician education and engagement with people. People on these medicines were invited to attend an educational session to discuss the risks and long-term effects of these medicines, and they were then encouraged to attend a review clinic for further discussion and support in stopping these medicines. Phase 3 was underway with people being booked into dedicated clinics to support them through this process.

The practice worked in collaboration with a local pharmacy to refer people under the Pharmacy First scheme so that people could be seen and treated immediately for certain conditions by a pharmacist.

Leaders worked in partnership with the PPG to gain their feedback, share updates with PPG members and together share information more widely to people who lived locally.A number of PPG representatives provided positive feedback regarding the practice’s engagement and openness with the PPG, and provided examples of improvements made, for example in relation to access.

One of the GP Partners was the co-clinical director of the Wolsey Primary Care Network (PCN). (Primary care networks are groups of practices who work together to improve primary care services). We received positive feedback regarding the practice leadership and oversight which had fostered a culture of openness, innovation and shared purpose. Arrangements were in place for extended access appointments for people on a Wednesday evening.

The practice engaged with commissioners and provided timely responses when information was requested.

The service focused on continuous learning, innovation and improvement across the organisation and local systems. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. There was a learning culture in the practice which staff and leaders actively encouraged and participated in.

The practice was a training practice for medical students and GP Registrars (qualified doctors training to become GPs). They had 2 GP trainers, 3 associate trainers and currently had 2 GP Registrars working at the practice. Stakeholders fed back that practice worked collaboratively with partners. For example, they had accommodated GP Trainees at short notice, along with accommodating long term placement requests.

The practice completed clinical audits to ensure the quality and safety of people’s care and treatment was effectively monitored.

Practice leaders had embraced digital innovations to improve access, streamline workflow and enhance clinical decision making. Examples included the implementation of an online consultation platform and cloud-based telephony. These systems had improved telephone access and satisfaction of people who used the service. The service had improved their ability to respond more flexibly to access challenges.