Highlands 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

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.

People and communities had outcomes that were consistently better than expected when compared with other similar services.

There were some areas to improve, but people’s feedback about the effectiveness of the service described it as exceptional and distinctive.

Leaders inspired a culture of improvement, where understanding current outcomes and exploring best practice was a deeply embedded part of the culture, and learning was widely shared and acted on.

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

This service scored 83 (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 were involved as much as possible in the assessment of their needs, and support was provided where needed to maximise their involvement.

People were confident that their individual needs have been appropriately assessed and were fully understood.

People’s communication needs were appropriately assessed and met to maximise the effectiveness of their care and treatment.

People’s needs were assessed using a range of assessment tools to ensure their needs were reflected and understood.

Assessments considered the person’s health, care, wellbeing, and communication needs, to enable them to receive care or treatment that had the best possible outcomes.

Assessments were up-to-date and staff understood people’s current needs.

The needs of carers of people using services were also assessed and met. This supported their health and wellbeing in their carer roles and helped them to provide safe and effective care to the people they supported.

Feedback from people using the service was positive. People felt involved in the assessment of their needs and felt confident that staff understood their individual and cultural needs. GP patient survey for the period January 2024 – March 2024 showed that the practice performed better than the national average in some indicators:

79% responded positively to the overall experience of their GP practice, which was above the national average of 73.9%

85.7% stated that during their last appointment the healthcare professional was very good or fairly good at listening to them which was slightly below the national average of 86.7%.

89% stated that during their last appointment the healthcare professional was very good or fairly good at treating them with care and concern which was above the national average of 85.3%.

89% stated that during their last appointment they had confidence and trust in the healthcare professional they saw or spoke to which was slightly below the national average of 92.3%.

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.

Clinical staff used electronic templates when conducting care reviews to support the review of people’s wider health and wellbeing. The practice had effective systems to identify when people needed to be referred to other services for care and treatment.

The practice employed an emergency care practitioner who provided support to care homes, families and people who were receiving palliative care, and provided home visits as directed by clinicians. Feedback from people who had benefited from this service was very positive. We saw examples of situations where there had been a positive impact for people, including avoiding hospital admissions.

Staff were also able to refer people with wider needs, including those experiencing social isolation, bereavement or housing difficulties, to a social prescriber, who was employed by the practice. The social prescriber had produced a comprehensive directory of local services and information, which was audited and updated regularly, often on a daily basis. This was accessible for all staff to access if they needed to signpost patients. There were many examples of innovative interventions which led to positive outcomes for patients who had accessed the services of the 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.

Information on best practice was cascaded to staff at clinical meetings and via newsletters and emails and online messaging groups.

The practice held regular and well-attended patient review meetings, which included relevant members of the local multi-disciplinary team. There was a set agenda for these meetings and minutes were recorded. There were very positive and professional working relationships between practice staff and their multi-disciplinary colleagues, and this ensured timely exchange of communication to ensure patients received the care they needed. The practice and staff from the multi-disciplinary organisations all shared the same clinical IT system. This meant that information about patients could be shared in real time, avoiding the need for patients to have to explain and repeat their situation multiple times.

The service always worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once.

Leaders proactively lead and co-ordinated partnership working across the wider locality. There was exceptional working across teams and services to support people. This included, amongst many examples, working together to lead improvements with the local safeguarding team, the voluntary sector and commissioners. People only needed to tell their story once as their assessment of needs was shared when they moved between different services. When people received care from a range of different staff, teams or services, it was co-ordinated effectively. All relevant staff, teams and services were involved in assessing, planning and delivering people's care and treatment and staff worked collaboratively to understand and meet people's needs.

When people were due to move between services, all necessary staff, teams and services are involved in assessing their needs to maintain continuity of care.

Staff demonstrated good working relationships with both local NHS Trusts and used those relationships to support patients to navigate the complex health and social care system, including proactively contacting the hospital for test results. The practice regularly hosted speakers at time to learn events to raise awareness of partner services and delivered internal sessions to help staff understand how external contracts were funded and delivered.

Staff and leaders, including social prescribers developed and maintained positive partnership arrangements with many local providers and charities, including bereavement services, the mental health team, carers services and a wide range of social support providers.

People were supported to manage their health and wellbeing so they could maximise

The service supported people to lead healthier lives and manage their own health and wellbeing. Staff took a proactive approach to identifying risks to patients’ health, including those in the last 12 months of life, individuals at risk of developing long-term conditions, and those with caring responsibilities. They led and contributed to both local and national health priorities, such as smoking cessation, and actively encouraged uptake of national screening programmes. Positive outcomes were evident through high participation rates. Cervical screening uptake exceeded the national target of 80%. People were also encouraged and supported to make healthier lifestyle choices to promote their wellbeing and prevent deterioration.

We saw that there were many examples of staff working in partnership with people to create tailored interventions to provide the best outcomes for them and have a positive impact on their health and well-being.

There was strong monitoring and oversight of urgent referrals, with robust failsafe systems in place to ensure patients attended their two-week wait appointments. Individuals living with long-term conditions were regularly monitored and, where appropriate, referred or signposted to local services offering information, education, and tailored support. We saw clear evidence of collaborative work with the Primary Care Network to initiate and support local initiatives, including those related to people with a learning disability, those with cancer, and immunisations.

Leaders had recently signed up and subscribed to Sleep Station which is an NHS programme to help people to overcome insomnia and other sleep issues. This programme gave people the opportunity to consider the underlying causes of their insomnia and to address those causes as an alternative to prescribed medication. The practice was able to refer people onto the scheme at no cost to them and take-up was increasing with patients reporting positive impacts on their sleep patterns and overall well-being.

A review of the clinical record system confirmed that patients were receiving care and treatment aligned with healthier living. The practice had also made a significant investment in staff training to support these aims.

The service monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they fully met both clinical expectations and the expectations of people themselves.

People told us that they were contacted to attend a health monitoring appointment, and they stated that the information they received was easy to understand and helpful.

The practice met or exceeded national targets for screening and immunisations. They exceeded the World Health Organisation (WHO) target of 95% uptake in 4 out of 5 childhood immunisations indicators and achieved the target of 95% uptake in the remaining indicator.

The practice maintained a programme of 1and 2 cycle clinical audits alongside a programme of non-clinical audits which facilitated learning and drove improvement.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. Staff we spoke with demonstrated the importance of ensuring that people understood what they were consenting to and the importance of obtaining consent before they delivered care or treatment. Clinical and non-clinical staff had undergone training in the Mental Capacity Act and clinical staff understood the requirements of legislation and guidance when considering consent and decision making.

Discussions with staff and feedback from patients confirmed information was given to help people to make an informed decision about their care including making plans about what treatment was wanted at the end of their life.

Staff understood the requirements of legislation and guidance when considering consent and decision making.

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. Relevant documentation was also demonstrated in the care records of patients who did not have capacity to make decisions.