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Inspection carried out on 18/07/2019

During an inspection looking at part of the service

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

Review carried out on 17 April 2019

During an annual regulatory review

We reviewed the information available to us about Kippax Hall Surgery on 17 April 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 8 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kippax Hall Surgery on 8 December 2015. Overall the practice is rated as good for providing safe, effective, caring, responsive and well-led care for all of the population groups it serves.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system was in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and were involved in care and decisions about their treatment.
  • Patients were positive about access to the service. They said they found it easy to make an appointment, there was continuity of care and urgent appointments were available on the same day as requested.
  • The practice had good facilities and was well equipped to treat and meet the needs of patients.
  • The practice sought patient views how improvements could be made to the service, through the use of patient surveys, the NHS Friends and Family Test and the patient participation group.
  • There was a clear leadership structure and staff were supported by management.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

We saw some areas of outstanding practice:

  • The practice had a system of priority booking of appointments for carers and patients who were on the palliative care register.
  • During the times staff acted in the capacity of a chaperone, they wore a tabard and badge citing ‘chaperone’ to enable patients to identify that member of staff was carrying out the role.
  • The practice had developed a visual ‘jobs to do’ board to ensure all tasks were completed in a timely manner and to avoid duplication of work. Morning, afternoon, weekly and monthly tasks were identified. The use of different coloured markers identified when the task had been completed.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice