Kippax Hall Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that the leadership, management and governance of the practice assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. All staff we spoke with showed a clear desire to provide the best treatment and care to their practice population. The provider had a good understanding of the challenges faced in the delivery of the vision, and aims of the provider. For example, they were fully aware of their increasing practice patient list, and the limited capacity within the practice to deliver against this demand, and were constantly examining options to deal with this. Actions included risk assessing automated systems such as auto filing pathology results, and automated telephone line booking for repeat prescriptions. We saw for a limited time that the practice had closed its list to new patients, but that this had now reopened. Staff we received feedback from told us that the practice had a supportive and positive culture and that teams within the practice all worked closely together.

The service had inclusive leaders and managers at all levels who clearly understood the context in which they delivered care, treatment and support. Leaders and managers had the skills, knowledge, experience and credibility to lead effectively, and we saw they did so with integrity, openness and honesty. From staff interviews and questionnaire feedback we heard that leaders and managers were approachable, supportive and friendly. We were also told that staff felt that the practice looked after their wellbeing, and that they felt that they were able to raise concerns openly. As well as direct feedback, the provider had undertaken a staff survey in 2024 which showed that staff overall were satisfied working at the practice. We saw the management team worked with other practices in the primary care network (PCN) and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where people felt they could speak up, and their voice would be heard. The provider had established freedom to speak up arrangements, and all staff we spoke with knew how to and who to contact if they had a concern that they wished to discuss with them. We saw that the Freedom to speak up guardian was external to the practice. Freedom to speak up had been subject to a recent training event to further raise awareness amongst staff, and to support this work we saw that a freedom to speak up policy and procedure had been adopted and implemented. We heard from the provider how they dealt with general concerns and issues raised by staff. Leaders and managers told us that they had an open-door policy, and were open to direct contacts from staff when they had concerns, issues, or suggestions to improve the operation of the practice. Staff views confirmed that they worked well with the management team, and felt they could approach managers.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. We saw that there were key policies and procedures in place to promote diversity and equality were in place, which included a bullying and harassment policy, and a policy for dealing with unreasonable, violent and abusive patients. Our review of training records showed that staff had all undertaken training regarding equality and inclusion. The provider had undertaken a staff survey in 2024 which showed that the majority of staff were enthusiastic about their job, and would also recommend the practice as a place to work. Adjustments had been made to ensure all staff were valued and supported. The provider had a positive attitude to training, and we heard that staff had received additional training that allowed them to develop their careers. The practice also supported the training of first and second year medical students.

The provider had developed clear responsibilities, roles, and systems of accountability. They used these to manage and deliver good quality, sustainable care, treatment and support. The provider had a defined organisational structure in place which included regular partners meetings, clinical governance meetings, clinical team meetings for senior staff members, and also wider team meetings. For example, clinical governance meetings were attended by senior clinical staff and discussed key issues such as NICE updates, audits, medicines and patient safety alerts, patient deaths and significant incidents. We saw that minutes were detailed with any actions delegated to staff, and were available to staff who were unable to attend. Staff told us they had access to policies and procedures to support them within their role. Leaders and managers told us about the ways in which they monitored and mitigated risks and had oversight of performance. For example, they clearly understood the challenges of capacity and demand and had worked to put in place measures to manage this through introducing new appointment processes, and via enabling and supporting patients to access test results themselves via the NHS App. The provider closely monitored key areas of performance such as capacity and telephony data and used this to plan future developments. Staff informed us that they felt well supported, and felt well informed of developments within the practice via team meetings and direct communication with line managers. Managers and line managers met with staff regularly to complete appraisals and performance reviews. During our remote searches we saw that workflows for communication, tasks, and pathology results were up to date. The provider had succession plans in place, and we saw that measures were underway to manage the future loss of key staff members. The provider also had a business continuity plan in place, which outlined how the practice would maintain or quickly resume essential functions in the face of a disruption, such as a loss of IT or a fire.

The service understood their duty to collaborate and work in partnership with others, so services worked seamlessly for people. They shared information and learning with partners, and collaborated to achieve improved services and outcomes for patients. For example, we saw that the provider hosted a number of services in conjunction with PCN such as health and wellbeing coaches, pharmacy staff, and a frailty team. In addition, we saw that they meet regularly with a range of stakeholders and partners which included those involved in palliative care, health visitors, and the Leeds GP Assembly. The provider engaged actively with their patients and supported a Patient Participation Group (PPG), and was working with others to establish a group at PCN level.

The provider focused on continuous learning, innovation and improvement across the organisation. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. The provider had participated in the General Practice Improvement Programme in 2024 and had focused on activities to increase access and practice capacity, improve the website to meet NHS standards, increase the take up and usage by patients of the NHS App, and further develop staff to deliver other duties and roles safely and effectively. We saw that progress had been made in all these areas. Where performance had been recognised as needing to be improved the provider had put in place measures to tackle this. For example, by increasing patient engagement and contact, we saw that the flu immunisation uptake for carers had risen from 61% to 82% in 2025. The provider had also identified an issue with the process for automatically linking hormone test results to patient records, and had worked to rectify this and shared this learning with others. Quality improvement activity including clinical audit findings were discussed at regular clinical meetings and other learning events. The provider also worked in conjunction with others to improve health and care, and we heard from managers how they had undertaken work in relation to kidney health, type 2 diabetes, asthma, and chronic obstructive pulmonary disease in the previous 12 months.