Kippax Hall 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 with advice and support.

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

This service scored 79 (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. Patient feedback from the 2024 National GP Patient Survey indicated that satisfaction with how the practice worked with them to assess their needs was generally above local and national averages. For example, 96% of respondents reported that the healthcare professional they saw or spoke to was good at listening to them at their last general practice appointment compared to the local average of 86% and the national average of 87%. Feedback from a representative of the Patient Participation Group confirmed that the practice staff worked closely with them to assess needs, and explain treatments. Staff were aware of the health and care needs of the local community they served, and checked patients’ health, care, and wellbeing needs during booking into the service, and during health reviews and consultations. Members of staff working on reception had received training in care navigation which allowed them to signpost patients to more appropriate services, and patients were also able to utilise an NHS non-urgent online consultation service to have their clinical needs assessed. The provider had effective systems to identify patients with previously undiagnosed conditions. In addition, we saw that patients with long-term conditions such as asthma received regular reviews, and after events when their condition had deteriorated. Patients with communication needs were taken into account, and they were supported accordingly, for example through the provision of a hearing loop, and the use of interpretation and translation services. The practice held a register of end of life care patients, and used this to effectively manage their care in coordination with other services. At the time of our assessment 50 end of life care patients were registered with the practice.

The service planned and delivered people’s care and treatment with them. They did this in line with legislation and current evidence-based good practice and standards. Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with this guidance. New guidance was discussed within the practice at clinical governance and clinical team meetings, and also shared with others when appropriate. As an example of actions taken, we saw that the provider had noted the release of new NICE guidance in 2023 which outlined that prescribing specific type of medicine could improve outcomes for adults with type 2 diabetes, chronic kidney disease (CKD) and some other long-term conditions. After receipt of this guidance we saw that that 8 potential patients had been identified and, after discussing this with them, that 7 patients had agreed to receive this additional treatment.

The service worked well across teams and services to support people, and shared their assessments of need when people moved between different services. We saw that staff had access to the information they needed to appropriately assess, plan, and deliver people’s care and treatment. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. We heard for example, how staff were able to refer on to other specialist services for enhanced patient care such as tissue viability nurses. The provider also worked closely with their primary care network (PCN) pharmacy team, members of which undertook duties which included medicines reviews and medicines reconciliation. A representative of the pharmacy team told us that they worked effectively with the provider to deliver patient care.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support. Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients who were at risk of developing a long-term condition, and those with caring responsibilities. The provider delivered a range of health assessments which included NHS health checks, new patient checks and learning disability health checks. We saw during our remote clinical searches that processes were in place to diagnose and support patients at risk of developing conditions such as diabetes and chronic kidney disease. Staff had been trained, and could refer or signpost patients with specific needs to other organisations. Working within their primary care network, the provider had access to social prescribers and health and wellbeing coaches. In addition, patients had access to additional services including first contact physiotherapy, and abdominal aortic aneurysm screening.

The service routinely monitored people’s care and treatment to continuously improve it. They sought to ensure that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves. We saw that overall patients with long-term conditions had been well managed and that processes were in place to identify, recall, and monitor such patients. Clinical audit was used to support this activity, and ensured treatment and outcomes were assessed in line with guidance. For example, all patients with hypothyroidism had received the necessary monitoring. The provider met national targets for child immunisations and vaccinations with all 5 measures used to assess compliance being above the 95% WHO target. The provider had achieved a cervical screening attainment of 79.5% against a national target of 80% in 2023, and we saw unverified data from the provider that the latest performance was around 80.4%. The provider told us that they had a dedicated invitation and recall procedure for both child immunisations and vaccination, and cervical screening. This involved writing to and then calling the parent or patient to discuss the need to participate, and in the case of child immunisations sending an online consultation link with an embedded video to raise awareness and promote participation. When identified, staff also undertook opportunistic vaccinations, immunisations, and screening. Staff actively supported vulnerable patients for health checks, and screening. As examples, we were told how staff supported a vulnerable patient to receive the necessary care including screening, and saw that the practice had delivered learning disability health checks to 96% of patients on their learning disability register. The provider kept a register of carers and had identified 211 at the time of our assessment (3.1% of the practice population). They had a carers champion to support these patients, and had in 2025 successfully raised carers flu uptake from 60.9% to 82.4%.

The service told people about their rights around consent, and respected these when delivering person-centred care and treatment. The provider had developed and adopted a consent policy which had last been reviewed within the previous 12 months, and which outlined the practice’s approach to consent processes. Staff we spoke with all had a good understanding of consent, including care which would require more detailed written consent, considerations to be given when providing care to children and young people, and the need to assess the mental capacity of patients to give consent. We saw that staff had received appropriate training in the requirements of mental capacity legislation and best practice principles. From a search of 5 patient records, we saw that ReSPECT forms (Recommended Summary Plan for Emergency Care and Treatment – a document which holds personalised recommendations for a person's clinical care in an emergency), which included decisions related to Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were accessible to staff, and had been completed in line with relevant legislation.