Ixworth Surgery

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• 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

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support.

This key question has been rated as good.

People were involved in assessments of their needs and staff reviewed people’s communication, health, and wellbeing needs. Care and treatment were based on latest evidence and good practice and was regularly reviewed. Staff worked with a range of partner agencies involved in people’s care for the best outcomes and smooth transitions when moving between services. People were supported to live healthier lives. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people and took decisions in people’s best interests where they did not have capacity.

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 and reviewing their health, care, wellbeing and communication needs with them.

People and care home representatives gave positive feedback in relation to how people’s needs were assessed by clinicians and the clinical care and treatment they received. People felt involved in the assessment of their needs and confident staff understood their individual needs.

Staff told us they had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. Staff involved people, and their carers in assessments where appropriate. Systems were in place to identify people with caring responsibilities. The service held a carers’ registerand 5.5% of the practice population were registered as carers. They had a Carers’ Champion who provided support, including signposting to services such as Suffolk Family Carers. The social prescriber also wrote to carers who had newly registered to explain their role and how to contact them. There was an information table for carers in the waiting room.

Staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for an extended appointment or for an interpreter to be present. Clinical staff used templates when conducting assessments and care reviews to support the review of people’s wider health and wellbeing. The service had effective systems to identify people with previously undiagnosed conditions.

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.

People and care home representatives gave positive feedback in relation to the clinical care and treatment received and told us they were looked after well. Staff told us they were supported by leaders to stay up to date with current guidance and evidence-based practice through clinical meetings, training days, and learning from audits.

In September 2025, the provider introduced a new system for long‑term condition monitoring. People were now invited based on their month of birth, and reviews for those with multiple long‑term conditions were coordinated.

There were effective systems for monitoring people with chronic kidney disease stages 4 or 5, and people with hypothyroidism. We searched for a potential missed diagnosis of diabetes and identified from a sample of 5, 2 people had not been coded. At the site visit we found the appropriate coding had been added to their record. A further search identified out of 684 people with diabetes; 81 people had a blood result which was above the recommended level. We reviewed a sample of 5 people. People had received monitoring, and the service demonstrated they worked to engage with people who found compliance difficult. At the site visit the provider advised they had arranged dedicated time for 2 clinicians to review all people identified in these diabetes searches.

The service had pop up alerts in people’s clinical record to support safe and effective care. These included for people overdue monitoring.

The service worked well across teams and services to support people. For example, the safeguarding administrator and social prescriber met regularly with their peers to learn from each other and share best practice. The service had supported reception and administration staff to become multiskilled to cover both roles. This enabled staff to work flexibly in response to peak times of demand from people using the service and minimised the impact of unexpected staff absence. Cover arrangements were in place during times of absence. The service shared assessments of people’s needs when they moved between different services.

Representatives from care homes gave positive examples of how they worked together effectively with staff. People gave positive feedback about staff being helpful and proactive. Partners agencies gave positive feedback, such as joint visits being undertaken, staff being treated with respect and being appreciated by staff.

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.

The service supported national health priorities such as smoking cessation and obesity reduction, and staff gave examples of where people had been positively supported to live healthier lives. The service had arrangements in place to offer NHS health checks to eligible people aged 40 to 74 years. People aged 75 and over could request a health check. A health kiosk was available in the waiting area where people could carry out a variety of health checks to support their wellbeing. Arrangements were in place to record results on the persons clinical record and escalate results, which were outside of the agreed range, to a clinician. Processes were in place to identify and support people at risk of developing a long-term condition.

Arrangements were in place to offer people with a learning disability a health check. People were sent an easy read pre-health check questionnaire with pictures to complete before their appointment. Reasonable adjustments were in place to support people’s attendance. After the appointment, the social prescriber reviewed the health check and where appropriate, contacted the person and their parents and carers to offer support and signpost them to relevant organisations.

Staff referred people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. They also supported people to continue living independently in their own homes. People could self‑refer to the social prescriber. People who provided feedback for this assessment had no specific views or concerns in this area.

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.

People and care home representatives gave positive feedback in relation to the clinical care and treatment they received. 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. The service monitored and improved outcomes for people by carrying out clinical audits.

The service performed in line with the national average for breast and bowel cancer screening. Childhood immunisation rates met or exceeded national targets. Cervical screening uptake was slightly below the 80% target in both the 25 to 49 and 50 to 64 age group. Arrangements were made to encourage attendance, such as explaining what to expect during appointments, showing equipment in advance, and offering flexible appointment times, which included early mornings and evenings. Reasonable adjustments were made to support access. The provider advised they would strengthen their follow up arrangements for people who did not respond to an invitation or attend their appointment.

The service told people about their rights around 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. Feedback from care home representatives showed clinicians involved people, and their families when appropriate in clinical decisions.

The service had systems and processes in place to obtain consent to care and treatment in line with legislation and guidance. Clinical staff had completed training and understood and applied legislation relating to consent. Clinicians told us they always obtained consent from people, and we reviewed a sample of people’s records where consent had been recorded on the clinical system. The service displayed posters at the service and information was on their website to inform people that a chaperone was available if needed.