Kippax Hall 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

We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination. We saw that patients had good access to the practice and the services it provided, and that they received care and treatment that was responsive to their needs.

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

This service scored 75 (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 patients were at the centre of their care and treatment choices. Patients had access to appointments provided by clinicians including GPs, the nursing team and pharmacists, as well as additional support via referral to other specialist services. The National GP Patient Survey results from 2024 showed high levels of patient satisfaction. For example, during their last general practice appointment, 98% of respondents stated they were involved as much as they wanted to be in decisions about their care and treatment. This was above the local and national average of 91%. Care records reflected physical, mental, emotional, and social needs of patients including those related to additional needs such as communication requirements. Staff had received additional training to support specific population groups, this included those with a learning disability or autism. The provider respected the individual preferences of patients, and when making an appointment patients were able to choose either a face to face or telephone consultation.

Leaders had a good understanding of the diverse health and care needs of their patient population. We saw that as part of their General Practice Improvement Programme activity they had undertaken a practice level needs assessment, and had shared this with staff at one of their regular training meetings. The needs assessment covered issues such as health condition prevalence, and key at risk or otherwise vulnerable groups. The assessment also outlined some key processes and procedures to keep these patients safe and healthy. For example, by raising staff awareness of transgender issues, and ensuring transgender patients received necessary health screening. The provider worked in close collaboration with other partners including their primary care network (PCN) and the Pharmacy First minor ailment scheme. Where referrals were made to external services, these were monitored and followed up appropriately. There was an integrated approach to patient care, and the provider reported that services worked well together. We saw that some services, for example first contact physiotherapy, and health and wellbeing coaches were offered onsite.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. We saw that following participation in the National General Practice Improvement Programme in 2024, the provider had reviewed their website to update it to reflect changes such as new appointment processes. The website contained other key information which included details of opening times, prescription ordering advice, details of available services and clinics, how to raise concerns, and out of hours contact information. The provider produced a regular newsletter which included topical information for patients on subjects such as appointments, accessing test results and car parking. Adjustments were made to support the communication needs of patients; this included the use of translation and interpretation services. Individual communication needs were noted on the patient’s record where relevant. Leaflets were available in the reception area, and posters were displayed to provide patients with information. Staff from the practice had supported patients to improve their understanding and usage of the NHS App.

There was an active Patient Participation Group (PPG) in place which met regularly. A member of the PPG told us that they felt supported by the practice, and that the practice respected and took notice of their views. For example, they had implemented a suggestion made by the PPG to improve confidentiality and privacy at the reception desk by playing a radio in the waiting area. We saw that the provider routinely sought patient feedback following an appointment. Overall patient feedback was very positive. An in-house patient survey undertaken in February 2025 showed 96% of 241 respondents were either satisfied or very satisfied with appointments. Patients could also give feedback via the NHS Friends and Family Test (FFT), and the annual National GP Patient Survey. The provider told us that findings from patient feedback, including complaints, was reviewed formally at management team meetings and were shared with staff. Patient feedback also formed part of some of the provider’s clinical audits. For example, feedback on a regular quarterly audit into long-acting reversible contraception (LARC) implants last held for January to March 2025 showed high patient satisfaction. There was a complaints policy, and a complaints lead had been appointed. Staff we spoke with understood the complaints process and how to assist patients with any complaints or concerns they may have. Information on how to complain was also available on the practice website. We reviewed 2 complaints and found they were actioned in an appropriate and timely manner, discussed in meetings, and that learning was shared with staff. Where appropriate, patients were provided with an apology and signposted to the Parliamentary and Health Service Ombudsman if they wished to escalate their concern. Managers and staff told us how learning from complaints was used as an opportunity for improvement. We saw that changes had been made within the practice as a result of patient feedback. This included supporting patients with access and use of the NHS App, moving telephone appointments to set specified times rather than calling within a 2-hour window, and undertaking a telephony audit to improve patient experience.

The service made sure that people could access the care, support and treatment they needed when they needed it. The service offered a range of appointments from 8am to 6pm Monday to Friday. Bookings and requests for services could be made in person, via the telephone and using an NHS online consultation service. Bookings for some services could be made up to 3 months in advance. The practice had systems in place which ensured there were appointments available on the day, and patients were given the choice whenever possible of either a face to face consultation or a telephone consultation. In addition to appointments at the practice, by working within their primary care network (PCN) patients had access to weekend appointments with GPs, advanced nurse practitioners, and healthcare assistants, and weekday evening appointments (Monday to Thursday) with pharmacists for medication reviews and medication queries. The provider also hosted a range of other services which included PCN social prescribers and wellbeing staff such as a health and wellbeing coach. In addition, they had access to physiotherapy support, and screening services including abdominal aortic aneurysm screening. Patients had been supported by the practice’s NHS App Champion to access the NHS App and gain a better understanding of its usage and capabilities. As part of their General Practice Improvement Programme work in 2024 the provider had worked to improve accessibility, and how capacity and demand was managed. Outcomes included the development of new rotas, the introduction of patient preferences for types of appointment for example, choices of face to face or telephone appointments, fixing set times for telephone consultations, and increasing the number of appointment types that could be booked remotely, such as baby immunisations. The provider told us that they planned to increase the number of GP appointments available by 58 per week. In order to increase capacity, the provider had developed and adopted a skills matrix and trained staff to allow the wider and safer delegation of duties to staff. Patient satisfaction with the service in respect to access and overall satisfaction with the practice was high. For example, 77% of respondents to the 2024 National GP Patient Survey found it easy to get through to the GP practice by telephone compared to the local average of 47% and the national average of 50%.

Staff understood the importance of providing an inclusive approach to care, and made adjustments to support equity in people’s experience and outcomes. This included the use of interpreters, the provision of detailed advice and signposting, and providing longer appointments where needed. Staff received equality and diversity training, and had received specific care navigation training to signpost patients to services most appropriate to their needs. We saw that the practice offered and undertook health checks including NHS health checks, new patient checks, and learning disability health checks. In the previous 12 months we saw that the provider had undertaken 96% of their disability health checks, and had appointed a dedicated healthcare assistant to support this work. The provider recognised that certain groups and communities needed additional support and had put measures in place to achieve this. This included training staff to recognise needs and deliver dedicated care to service veterans and their families, and ensuring transgender patients received necessary recalls for screening, and were appropriately supported for any other health concerns they had. Managers and staff told us about the ways in which they supported national initiatives to engage with and educate patients, for example signposting or referring patients for weight management and smoking support. Using staff from their primary care network (PCN) they offered a range of services including a health and wellbeing coach and both an adults and a younger persons social prescribing support worker. In addition, the provider could refer vulnerable elderly patients to their PCN frailty team.

Staff understood the requirements of legislation when considering consent and decision making when patients were making decisions for their future care needs, and had access to policies and advice to support them. Staff helped and supported patients to make informed decisions about their future, including at the end of their life. The provider had 50 patients on their palliative care register. We saw that patients on the register were reviewed regularly in conjunction with other health and care providers. Staff told us how they worked with patients, and their carers, to support their understanding of their future care options. We saw that ReSPECT forms were completed in line with guidance.