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Inspection Summary

Overall summary & rating


Updated 22 August 2019

As part of our inspection programme we carried out an announced focused inspection at Kippax Hall Surgery on 18 July 2019.

We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions: are services effective, responsive and well-led.

We based our judgement on the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services
  • information from the provider, patients, the public and other organisations.

We have rated this practice as good overall and good for all population groups.

We found that:

  • There was a range of risk assessments regarding the new building works, to minimise risks to the health and safety of patients and staff, and disruption to the service delivery.
  • There was provision of continuity of care for existing patients, whilst also managing the care and treatment of newly registered patients.
  • There was a comprehensive system in place for the review and management of NICE guidance, local guidelines, protocols and pathways to ensure effective care and treatment were provided for patients.
  • There was evidence of quality improvement, which included a programme of audit and benchmarking against other practices.
  • Patients received structured reviews of their care and treatment and received advice and support to manage their symptoms.
  • The practice was above the national target for the uptake of childhood immunisations and cancer screening programmes.
  • When a member of staff acted in the capacity of a chaperone, they wore a tabard and badge citing ‘chaperone’. This enabled patients to identify that the member of staff was carrying out the role.
  • Patients were positive about the practice. Patient satisfaction was maintained during the challenging period and was above the local average in some areas.
  • Support for staff was positive. There was a comprehensive staff development process, which included assessment of competency and identification of areas for further development. Leaders and managers were extremely praising of staff. There was a team ethos of working together to provide high-quality services for patients.

We saw the following area of outstanding practice:

  • The provider was able to demonstrate there had been strong collaboration, team-working and support across all functions when they had been faced with a sudden, significant influx of new patient registration requests. As a result of this the quality of care and patients’ experiences had been sustained during this challenging period.

Details of our findings and the evidence supporting our ratings are set out in the evidence table.

Dr Rosie Benneyworth BM BS MDedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas










Checks on specific services

People with long term conditions


Families, children and young people


Older people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable