Highlands Practice

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

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.

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

Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs. Reception staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. 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 provider had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

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.

We found that those patients with diagnosed hypertension were being treated above the appropriate threshold. In December 2025 the practice recorded 71.5% which was above the expected 69.5%.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Any changes were discussed in the monthly clinical meetings and daily staff meetings. Clinical records we saw demonstrated care was provided in line with current guidance.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

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, including where clinical tasks were delegated to 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.

The service had an imbedded system of providing health checks for those patients that needed regular monitoring. We found that, in March 2026 the practice had undertaken 66.7% of health checks for patients with a severe mental health illness (expected rate of 65.3%), and in the same time period 97% of learning and disability or Autism annual health checks had been completed (expected rate of 79%). The practice attributed this high rate of completion to the recall system that was in place.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The service was below national targets for screening and immunisations. For example, for the period 1 April 2024 to 31 May 2025, for children age 5 only 78.9% had received two doses of the MMR vaccination (expected 95%), and 83.2% of children aged 2 received the PCV booster (expected 95%). The practice recorded over the same period 83.2% (expected 95%) for children aged 2 attending for the measles, mumps and rubella (MMR) vaccination. However the practice met the target for children attending aged 1 for the primary course of immunisation for Diphtheria, Tetanus, Polio, Pertussis, Haemophilus, Influenza type b (Hib) and Hepatitis B (HepB), recording 96.7%. In March 2025 the practice recorded a score of 53.8% for new cancer cases resulting from an urgent suspected cancer referral, which was in line with the 53.9% that was expected. The service was unaware of the lower-than-expected uptake and had agreed to put an action plan in place to improve these outcomes. The practice already had in place a dedicated member of staff to liaise with patients and health visitors who were responsible for the recall of patients. 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 had a system of audit cycles in place to ensure good outcomes were achieved. This included an ongoing review of patients records to identify those who may have undiagnosed or incorrectly coded asthma, hypertension or diabetes. The records and clinical information were reviewed by GPs and further investigations or follow ups were arranged where required. Outcomes were then correctly coded on the patient notes.

The service also undertook an audit of patients that were diagnosed with female genital lichen sclerosis (a chronic inflammatory dermatosis affecting the anogenital skin). This followed concerns raised that some patients diagnosed may not have been receiving appropriate annual follow up. Of the 16 patients diagnosed, 9 had been discharged from gynaecology services back to the GP for follow up. None had received the follow up appointment. This was actioned by the practice by offering a follow up with the GP or offering a referral back to secondary services, depending on the time lapse between the original appointment with secondary services and the appropriate follow up with the GP. The practice planned to repeat the audit.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.