Highlands Surgery

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

The service was exceptional at making sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Staff used innovative and personalised approaches to involve people, their families, friends, and carers in care, treatment, and support planning. As a result, people felt consulted, empowered, listened to, and valued. Staff were trained to direct people to the most appropriate clinician or service to meet their needs and clinicians were available to see people on-the-day for all types of appointment requests.

Patient feedback highlighted that staff had an exceptional understanding of individuals’ needs, including those related to protected characteristics, social and cultural backgrounds, and personal values and beliefs that shaped how they wished to receive care.

At our last assessment, we rated this key question as Good. At this assessment, the rating has changed to Outstanding.

This service scored 89 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Results from the national GP survey (01/01/2024 to 30/04/2024) showed 83.8% of patients stated that during their last GP appointment they were involved as much as they wanted to be in decisions about their care and treatment. This was below the national average of 90.9%, but the practice had taken prompt action to find out more detail about this in a thematic patient survey and were able to address concerns in a timely manner. Information from Give Feedback on Care submissions to CQC included positive comments regarding GPs and other clinical staff listening and involving patients in decisions on care and treatment. Patients said they were listened to, and their concerns were dealt with in a compassionate manner. Staff were considered to be sympathetic, knowledgeable and kind.

We saw the use of innovative and individualised ways of involving people and their families and carers in their care and treatment, such as events that included the wider community. The service continually ensured that people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs. Feedback from Give Feedback on Care responses and from people we spoke to from the PPG and during the site visit said they were well supported to understand their condition and felt involved in decisions about their care and treatment and in planning for their future needs. We reviewed 24 months of data from the Friends and Family Test, and the vast majority of feedback was rated as either "good" or "very good." We also saw many written letters of thanks. Feedback included phrases like: can’t fault them, polite and caring, didn’t reel rushed, efficient and thorough, very lucky to have, second to none, you can always see the GP you want, everyone in Leigh wants to join this practice.

People who provided us with feedback consistently said they were given sufficient information to make a decision on care and treatment.

All calls and online requests were triaged by the on the day duty team, which included a GP who allocated them to the most relevant member of staff to manage. Triaging clinicians were able to book in follow up appointments in order to promote continuity of care. When needed an emergency care practitioner who was part of the acute on the day team was able to carry out home visits. The practice made reasonable adjustments when people found it hard to access services. There were arrangements in place for people who needed translation services. The practice complied with the Accessible Information Standard.

The practice knew their patient demographic exceptionally well and their patient list included a high number of working people who were unavailable during normal surgery hours. They accommodated this group of people by offering appointments including routine, screening, and vaccination appointments outside of working hours.

The diverse health and care needs of people and local communities played a pivotal role in the design of care provision, so care was joined-up, flexible and supported choice and continuity.

People received care and treatment from services that prioritised the diverse health and social care needs of their local communities.

Delivering and co-ordinating services prioritised and met the needs and preferences of different people, including those with protected characteristics under the Equality Act and those at most risk of a poorer experience of care.

We saw the practice worked in partnership with other services to meet the needs of its patient population, with many examples of positive outcomes for patient and the practice had tailored its services to meet the needs of its community.

There was excellent partnership working with the local Integrated Neighbourhood Team (INT), (previously Patient Aligned Care Team, PACT). We saw excellent communication between the practice and the INT, including fortnightly multi-disciplinary team meetings, tasks and messages communicated by a shared clinical system, and staff members from INT based at the practice for part of their working week. The practice worked with the INT to facilitate a service that identified frail patients, patients with long term conditions and additional care needs, and supported them to ensure they were optimally managed in their own home to reduce the risk of unplanned and unnecessary hospital admissions. As a result of this proactive approach to joined-up working, data showed that hospital readmission rates at 30 days had been reduced from 25% to 9%.

There were also established mechanisms for engaging with other community healthcare providers which produced positive outcomes for patients. The social prescriber in the practice had standard templates to work from for the common situations they were presented with, which meant that patients received consistent advice and guidance. The practice monitored and audited the outcomes for patients who had been referred to local community services by the social prescriber and continually reviewed their processes based on the results.

We saw examples of people who had accessed services through the social prescriber and who had received a variety of positive outcomes in terms of their wellbeing, including areas such as bereavement support, weight management support, social activities and others.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. For example, the practice encouraged people to use online processes and for those who found this difficult, a member of staff or a member of the PPG was available in reception to assist with such things as installing and using the NHS App, how to use the website to book an appointment, and how to use Voice Connect for ordering repeat prescriptions. This information support had improved the uptake of the use of electronic transactions: 65% of the practice patient population were using the NHS App, including 40 patients who had signed up in April 2025. There had also been 356 web chats during April 2025. Leaders had monitored and evaluated the increased use of online services and found that they had improved efficiency by saving 2 administration days during April.

The practice made changes so that information was provided in different formats, including verbal, written and text links prepared by the practice, to suit different peoples’ needs.

The practice’s website contained accessibility information. For example, people could request information on the practice’s website in a different format like large print, easy read, audio recording or braille. The practice designed its website to enhance accessibility.

The practice had access to interpreter services, including British Sign Language. Information provided by the service met the Accessible Information Standard.

People who faced barriers based on their protected characteristics could access the care, support and treatment they need when they needed it.

People could access care, treatment and support when they needed to and in a way that worked for them, which promoted equality, removed barriers or delays and protected their rights.

Care, treatment and support were accessible, timely and in line with best practice, quality standards and legal requirements, including those on equality and human rights. This included making reasonable adjustments for disabled people, addressing communication barriers and having accessible premises.

People could access services when they need to, without physical or digital barriers, including out of normal hours and in an emergency.

Leaders and staff were knowledgeable about, and pre-emptive in preventing discrimination and inequality impacting different groups of people in accessing care, treatment and support, whether this was from wider society, or within their organisational processes and culture.

Providers used people’s feedback and other evidence to actively seek to improve access for people more likely to experience barriers or delays in accessing their care.

Services were designed to make them accessible and timely for people who were most likely to have difficulty accessing care. When there were barriers, they were removed.

When services changed, equity of access is considered, and a wide group of people were consulted.

People had equal access to care, treatment and support because the provider complied with legal equality and human rights requirements, including avoiding discrimination, considering the needs of people with different protected characteristics and making reasonable adjustments. The provider prioritised, allocated resources and opportunities as needed to tackle inequalities and achieve equity of access.

Results from the national GP patient survey (01/01/2024 – 01/03/2024) showed:

68.6 % of patients responded positively to the overall experience of contacting the practice compared with the national average of 67.3% (no statistical variation).

33.7% of patients responded positively to how easy it was to contact the GP practice on the phone, compared with the national average of 49.7% (tending towards negative variation). In response to this, the practice had introduced quality improvement measures to improve patient telephone appointment access. This was reflected positively in the most recently published survey results where the percentage of patients who responded positively to the overall experience of contacting the practice was 86.5% compared to the national average of 69.6%. Leaders could show how data was used to flex appointment types, with the aim for the patient to be directed to the right person first time. The duty clinician was available to assist receptionists if they were uncertain of the type of appointment needed, thus avoiding the need for call-backs, reduce waiting times and reducing errors. Call data was used to assist with staffing levels. When needed the number of staff taking calls was increased and staff rotas were planned with more cover at peak times when trends showed call volumes were higher.

Results from the practice patient survey showed a higher response rate and a marked increase in patient satisfaction The number of patients who responded to this question in the national GP survey was 158.

The premises was wheelchair accessible, and there was lift access to clinical rooms on the first floor. The practice had a hearing loop. People could access appointments online, over the phone and in person. Pre-booked appointments at extended hours in the evenings during weekdays or on Saturdays were available at the practice to enhance access for working people and others who were unable to get to the surgery during normal opening hours.

The onsite duty GP triaged online requests and risk rated them so that urgent cases were seen in a timely manner. The duties that the duty GP carried out also enabled the other GPs at the practice to see more patients.

The practice offered a range of appointments. These included emergency on the day, pre-bookable and clinics for conditions such as diabetes or asthma reviews.

The duty GP was able to book patients in directly for a telephone consultation or face to face appointment, if needed after a patient was triaged. The provider prioritised and allocated resources and opportunities as needed to tackle inequalities and achieve equity of access. They maintained registers of people with protected characteristics and other status’ in order to be able to inform them of services available to support them.

People who faced barriers based on their protected characteristics could access the care, support and treatment they need when they needed it.

People could access care, treatment and support when they needed to and in a way that worked for them, which promoted equality, removed barriers or delays and protected their rights.

Care, treatment and support were accessible, timely and in line with best practice, quality standards and legal requirements, including those on equality and human rights. This included making reasonable adjustments for disabled people, addressing communication barriers and having accessible premises.

People could access services when they need to, without physical or digital barriers, including out of normal hours and in an emergency.

Leaders and staff were knowledgeable about, and pre-emptive in preventing discrimination and inequality impacting different groups of people in accessing care, treatment and support, whether this was from wider society, or within their organisational processes and culture.

Providers used people’s feedback and other evidence to actively seek to improve access for people more likely to experience barriers or delays in accessing their care.

Services were designed to make them accessible and timely for people who were most likely to have difficulty accessing care. When there were barriers, they were removed.

When services changed, equity of access is considered, and a wide group of people were consulted.

People had equal access to care, treatment and support because the provider complied with legal equality and human rights requirements, including avoiding discrimination, considering the needs of people with different protected characteristics and making reasonable adjustments. The provider prioritised, allocated resources and opportunities as needed to tackle inequalities and achieve equity of access.

Results from the national GP patient survey (01/01/2024 – 01/03/2024) showed:

68.6 % of patients responded positively to the overall experience of contacting the practice compared with the national average of 67.3% (no statistical variation).

33.7% of patients responded positively to how easy it was to contact the GP practice on the phone, compared with the national average of 49.7% (tending towards negative variation). In response to this, the practice had introduced quality improvement measures to improve patient telephone appointment access. This was reflected positively in the most recently published survey results where the percentage of patients who responded positively to the overall experience of contacting the practice was 86.5% compared to the national average of 69.6%. Leaders could show how data was used to flex appointment types, with the aim for the patient to be directed to the right person first time. The duty clinician was available to assist receptionists if they were uncertain of the type of appointment needed, thus avoiding the need for call-backs, reduce waiting times and reducing errors. Call data was used to assist with staffing levels. When needed the number of staff taking calls was increased and staff rotas were planned with more cover at peak times when trends showed call volumes were higher.

Results from the practice patient survey showed a higher response rate and a marked increase in patient satisfaction The number of patients who responded to this question in the national GP survey was 158.

The premises was wheelchair accessible, and there was lift access to clinical rooms on the first floor. The practice had a hearing loop. People could access appointments online, over the phone and in person. Pre-booked appointments at extended hours in the evenings during weekdays or on Saturdays were available at the practice to enhance access for working people and others who were unable to get to the surgery during normal opening hours.

The onsite duty GP triaged online requests and risk rated them so that urgent cases were seen in a timely manner. The duties that the duty GP carried out also enabled the other GPs at the practice to see more patients.

The practice offered a range of appointments. These included emergency on the day, pre-bookable and clinics for conditions such as diabetes or asthma reviews.

The duty GP was able to book patients in directly for a telephone consultation or face to face appointment, if needed after a patient was triaged. The provider prioritised and allocated resources and opportunities as needed to tackle inequalities and achieve equity of access. They maintained registers of people with protected characteristics and other status’ in order to be able to inform them of services available to support them.

Leaders and staff prevented discrimination and inequality that could disadvantage distinct groups of people using their services, whether from wider society, organisational processes and culture or from individuals. They proactively sought out ways to address those barriers to improve people’s experience, act on information about people's experiences and outcomes and allocate resources and opportunities to achieve equity. People’s care, treatment and support promoted equality, removed barriers or delays and protected their rights. For example, appointments for patients with a learning disability were structured and arranged to meet their needs and this was demonstrated by the fact that all patients on the learning disability register had attended for their annual review this year. We saw how the practice supported the different groups within their community by actively recruiting staff who were able to represent them, for example, carers, veterans and people from diverse backgrounds. People felt empowered by the service and its staff to give their views and understood their rights, including their rights to equality and their human rights, as fed back to us from the PPG. There were no incidents of inequality reported directly about the practice, but people knew their experiences of discrimination and inequality in the wider healthcare settings would be used by the practice to inform improvements of care. We saw that the practice shared and promoted best practice with other organisations. These shared initiatives were then used across the wider area.

Feedback provided by people using the service, both to the provider as well as to CQC, was positive. Staff treated people without discrimination. Leaders proactively sought ways to address any barriers to improving people’s experience and worked with local organisations, including the voluntary and community sector, to address any local health inequalities.

Staff understood the importance of providing an inclusive approach to care and made adjustments to support equity in people’s experience and outcomes. The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people and Travellers. Staff used appropriate systems to capture and review feedback from people using the service, including those who did not speak English or have access to the internet.

For transgender patients arrangements were in place to ensure they would continue to receive appropriate health checks, and their preferred name was used.

Systems and processes were in place to assist in identifying patients who may need extra support. This included alerts on patients records to show what support they needed with communication such as interpreters.

The practice was responsive to the needs of older patients and offered home visits and urgent appointments for those with enhanced needs and complex medical issues.

The practice adjusted the delivery of its services to meet the needs of people with a learning disability and autistic people and staff had received appropriate training. When the person or a carer / family member made contact with the practice to book their health check, the individual needs of the person were discussed and wherever possible they were met, including quiet time appointments, specific members of staff, and early or late appointments. As a result of this approach, the practice had achieved 100% uptake for health checks for a person with a learning disability.

The practice liaised regularly with the community services to discuss and manage the needs of patients with complex medical issues.

There was an equality, diversity and inclusion policy in place which was accessible to all staff and all staff had received training to improve their understanding and awareness.

Staff within the practice demonstrated exceptional skills and commitment in helping people, their families and/or carers to explore and record their wishes about care at the end of their lives and to plan how those would be met. We saw evidence from patients where they said they felt consulted, listened to and valued.

Our records review showed people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. This information was shared with other services when necessary. The practice had a named GP to coordinate and oversee decisions regarding advance care planning, end-of-life care, and DNACPR.

There was information in the reception area on palliative care and services offered by the practice, such as home visiting.

The practice fully engaged in regular, well attended multi-disciplinary team meetings to assess and support people in reaching decisions about their end-of -life care. This identified that peoples’ views had been sought and respected. Minutes of these meetings were recorded, saved and shared with relevant agencies.

We looked at a sample of ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions in patient records. Appropriately completed documents were available and had been shared with other relevant services and alerts had been added to the patient record system. Relevant documentation was also demonstrated in the care records of patients who did not have capacity to make decisions.

People’s needs had been prioritised as part of the end-of-life care plan and this had taken account of language, communication, ability to understand and capacity when decisions were made. It also took account of people’s desire to remain in their own homes for as long as possible, regardless of where that home was. There were members of staff with specific skills to understand and meet the needs of people and their families in relation to emotional support and the practical assistance they needed at the end of the person’s life. Evidence from a partner organisation described the practice staff as extremely responsive.

There were strong support and wellbeing arrangements in place for staff when impacted by the death of people they had cared for.