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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



Updated 25 February 2016

The practice is rated as good for providing responsive services.

  • The practice reviewed the needs of its local population and engaged with the NHS England Area Team and Leeds South and East Clinical Commissioning Group (CCG) to secure improvements to services where these were identified.
  • Patients we spoke with said they found it easy to make an appointment.
  • All urgent care patients were seen on the same day as requested.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was an accessible complaints system. Evidence showed the practice responded quickly to issues raised and learning was shared with staff.



Updated 25 February 2016

The practice is rated as good for being well-led.

  • It had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to this.
  • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings.
  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.
  • The provider was aware of and complied with the requirements of the Duty of Candour. (This is a legal duty on hospital, community and. mental health trusts to inform and apologise to patients if there. have been mistakes in their care that have led to significant harm.) The partners encouraged a culture of openness and honesty. The practice had systems in place for being aware of notifiable safety incidents.
  • Staff were encouraged to raise concerns, provide feedback or suggest ideas regarding the delivery of services. The practice proactively sought feedback from patients through the use of patient surveys, the NHS Friends and Family Test and the patient participation group. For example, with regard to access to the practice by telephone.
  • There was a strong focus on continuous learning and improvement at all levels.
Checks on specific services

People with long term conditions


Families, children and young 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