Kippax Hall Surgery

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm. Medicines were effectively managed within the practice, and we saw that patients were recalled for monitoring in line with guidance.

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 had a proactive and positive culture of safety, based on openness, and ongoing learning. To support this approach the provider had developed and implemented policies and processes for complaints, significant events and incidents, and quality improvement. These documents were available to staff on the shared information access platform. Staff told us that they felt confident that incidents reported would be investigated, and remedial action taken when required. We saw over the previous 12 months that the provider had recorded 62 incidents and events, and received 15 complaints. We saw that these had been investigated, and any themes or learning identified used to improve services. For example, we saw that an incident related to the assessment of patients prior to prescribing antibiotics had been investigated, and actions implemented to prevent a recurrence. Learning from this incident had also been shared with staff during a training event. Managers told us, and staff confirmed this, that they encouraged all those working at the practice to raise concerns when things went wrong. Governance and oversight in relation to learning events such as incidents and complaints were robust and were standing agenda items at practice meetings. This included partner’s meetings, clinical governance meetings, and clinical team meetings. The provider had appointed senior staff members from their clinical, and administration teams to lead on significant events and complaints.

The service worked with healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services. There were systems in place for processing information relating to new patients joining the practice. The provider had a rota in place for the summarising of new patient records, and we saw at the time of our assessment only 8 records were awaiting summarising. The service worked with other providers to deliver integrated and joined up services, including when patients moved between services. For example, when a patient was discharged from hospital their care needs were reviewed by staff. In addition, the provider worked closely with the local primary care network frailty team to support vulnerable elderly patients. We saw that referrals and test results were managed in a timely way, and that high priority referrals including cancer two week waits were subject to regular monitoring and audit.

The provider worked with statutory partners to keep people safe. The service had developed processes, policies and procedures to support this work, and staff had a good understanding of them, and were able to access them for reference. We saw that practice staff shared concerns quickly and appropriately with others to enable effective joined up partnership working. The provider had appointed senior health professionals to function as leads and deputies for child and adult safeguarding. All staff had been trained in safeguarding to the required level, and they fully understood their duties which included the identification of concerns, and how to escalate these. The practice computer records system allowed the sharing of information with other health and care providers, and was used to maintain a list of vulnerable people, and this was used this as a basis for the delivery of their safeguarding duties. Safeguarding was a standard topic area for team meetings, and had also been the subject of wider team training and awareness raising. Immediate safeguarding concerns discussed at daily short clinical meetings, along with any other emerging issues and concerns. Chaperones were available for patients who required additional support and assurance. The safeguarding lead had undertaken a review of safeguarding training requirements, and as a result changes had been made which included inhouse training sessions, and safeguarding being included in all clinical appraisals. The provider shared with us positive feedback from the Integrated Care Board safeguarding lead for their support in managing some very complex safeguarding cases.

The service worked with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, and supportive. Results from the 2024 National GP Patient Survey showed that 98% of patients reported that they were involved as much as they wanted to be in decisions about their care and treatment during their last appointment, compared to a local and national average of 91%. Staff could recognise the signs of a patient with deteriorating health, and knew of action to take to keep them safe and effectively respond to the situation. We saw that emergency equipment and medicines were available within the practice building, and saw that these were regularly checked and maintained. Staff had all received necessary training in basic life support, and emergency procedures.

The service worked to identify and control potential risks within the care environment. They ensured that equipment, facilities and technology available supported the delivery of safe care. The provider had put processes in place which gave assurance that health, safety and wellbeing requirements were met. For example, health and safety risk assessments had been undertaken and were available to staff on their shared IT system. Regular maintenance, servicing and calibration of equipment had taken place. Fire risks were managed, and we saw evidence that regular fire alarm checks and fire evacuation drills had been carried out, and that staff logged themselves in and out of the practice so their whereabouts could be accounted for in the event of an emergency. The provider undertook regular health and safety checks, and we saw that they had taken appropriate action to rectify any concerns identified. There was a business continuity plan in place which was monitored and reviewed.

Policies on recruitment, induction, and staff appraisals were in place and available to staff. We saw from records and feedback that staff had received regular appraisals. In addition to appraisals which were held annually, staff had monthly one-to-ones with their line managers, and were also able to meet with managers on an ad hoc basis. We reviewed 3 staff personnel files in detail as part of our assessment, and saw that records and documents related to their recruitment and training were in line with guidance. This included Disclosure and Barring Service (DBS) checks, and immunisation and vaccination records. Managers told us how they ensured staff were appropriately qualified and skilled to carry out their roles, and how they supported them to enhance their skills and qualifications. We saw evidence that staff clinical supervision had been undertaken to assess ongoing competency. Staff told us they had enough support to carry out their role, and were able to access advice and guidance from more senior staff when required. The provider had forward planning measures in place which ensured that there were enough qualified, skilled and experienced staff on duty, this included the running of monthly capacity reports, and the development of duty rotas.

The provider had measures in place to manage infection prevention and control (IPC). This included the appointment of a senior trained staff member to act as the practice’s IPC lead, the development of an IPC policy, and regular IPC audits being undertaken. When audits had identified IPC concerns, we saw that the provider had taken appropriate action. For example, past issues regarding standards of cleaning had been dealt with, and the last quarterly cleaning audit showed 97% compliance. However, during the onsite visit we identified further minor issues related to the standard of cleaning. We raised this with the provider who told us that this would be rectified and discussed with the contract cleaning company immediately. Staff undertook IPC training during their induction, and annually thereafter. We saw that as part of the recruitment process the provider had assurance that staff had received the necessary immunisations and vaccinations to undertake their roles safely. Hazards such as sharps risks were managed appropriately, and the provider had a clinical waste disposal contract in place.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved assessing patients current and ongoing needs. Staff received regular training, and felt confident managing the storage, administration and recording of medicines. The provider managed prescription stationery appropriately and securely. Protocols were in place which ensured medicines were prescribed safely, and that patients received recommended medicines reviews and monitoring. For example, all 29 patients prescribed Methotrexate (an immunosuppressant, which helps reduce inflammation, and is used to treat conditions such as rheumatoid arthritis) had received the required monitoring. In addition, only 2 patients out of a total of 1,005 prescribed ACE inhibitors or Angiotensin II receptor blockers (used to treat high blood pressure and heart failure) were outside the required monitoring period. Of these patients 1 was new to the practice and the other had been recalled, but had not yet received the monitoring required. We identified some other minor issues which we raised with the provider in relation to medicines management. When we discussed this with the provider, they took immediate action to rectify the issues. For example, whilst we saw that patients received regular medication reviews, some recorded medication reviews we examined carried little detail or supporting documentation within them. When we discussed this with the provider, they told us that they would examine this further and develop an agreed standard for reviews. In 2 out of 5 patient records we examined, we saw patients prescribed over 10 prescriptions for benzodiazepines or Z drugs (used to treat insomnia and anxiety and which can lead to dependence over time), contained no record of discussion regarding reducing use of the medication. We raised this with the provider, they told us that they would develop a protocol for these medicines, and also planned to book in specific reviews for those patients. Other prescribing data reviewed as part of our assessment confirmed that medicines were managed effectively. For example, the number of antimicrobials and other medicines issued by the provider was either lower than or in line with local and national averages. Effective prescribing practice was supported by a programme of regular clinical audits of prescribing that focused on improving care and treatment. For example, recent audits undertaken in 2024 and 2025 of patients in receipt of teratogenic medicines (medicines which can be linked to birth defects), showed that all patients of child bearing age had been informed of the risks associated with the medicines, and had received appropriate pregnancy advice and pregnancy prevention programmes in place. Staff regularly checked the stock levels and expiry dates for medicines stored within the practice, this included emergency medicines, and vaccines. Medical gases, such as oxygen, were stored safely, and required signage and completed safety records were in place. The provider had effective systems in place to manage and respond to safety alerts and medicine recalls. We saw that these had been discussed at clinical governance and clinical team meetings, and had been shared with staff.