The Microfaculty

We carried out an announced inspection at The Microfaculty on 9 July 2019 as part of our inspection programme, where we rated the practice as requires improvement overall as we identified breaches in regulation 17 of the Health and Social Care Act in relation to sharing learning and risk mitigation.

This inspection in January 2020 found significant improvements had been made.

We based our judgement of 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 and
• information from the provider, patients, the public and other organisations.

We have rated this practice as goo overall and good for all population groups.

We found that:

• The practice provided care in a way that kept patients safe and protected from avoidable harm.
• There were effective systems to share learning.
• Risks were adequately mitigated.
• Patients received effective care and treatment that met their needs.
• The practice organised and delivered services to meet patients’ needs.
• Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality care.

The practice should:

Continue to work to improve uptake of childhood immunisations and cervical cytology.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at the Microfaculty on 9 and 17 July 2019 as part of our inspection programme to review the information the practice sent to us post inspection.

We based our judgement of 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 and
• information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall and requires improvement for all population groups.

We rated the practice as requires improvement for being safe because:

• Systems and processes needed to keep patients safe and safeguarded from abuse needed improving. However, post inspection the practice provided us with evidence that improvements had been made.

• The processes for monitoring and managing high risk medicines was not effective. However, post inspection the practice provided us with audits of all patients on high risk medicines and where blood test monitoring was required this had been completed.

• The process for monitoring two-week wait referrals was not effective, but post inspection the practice provided us with evidence that all patients who had received a referral in the last six months had attended their appointment.

• There was no system to monitor staff training.

We rated the practice as requires improvement for being effective because:

• There was limited sharing of learning outcomes and actions taken as a result of audits.

We rated the practice as good for being caring because:

• The practice was rated in line or above average for patient satisfaction with services.
• Completed CQC patient comment cards and patients we spoke with all indicated the practice had a caring nature and were attentive to the needs of patients.

We rated the practice as good for providing responsive services because:

• Patients could access care and treatment in a timely way.
• The practice was rated in line with or above local and national averages to access to services.
• The practice offered extended hours appointments four days a week for patients who were unable to access the practice during normal opening hours.

We rated the practice as requires improvement for being well-led because:

• The practice vision was not supported by a credible strategy.
• There was limited evidence of sharing learning from quality improvement initiatives.
• There were insufficient processes for managing and mitigating risks.

The practice should:

• Continue to work to ensure that all improvements made are embedded and sustained.
• Review the system for identifying carers with the aim of increasing the registered number and ensuring they are all provided with the appropriate services.
• Review the system for sharing learning from audits.
• Review the system for documenting premises risk assessments.
• Review the system for monitoring and managing blank prescriptions.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care