During an assessment under our new approach
Date of assessment: 24 November 2025 to 24 April 2026. Mulberry medical practice is a GP practice and delivers service to 7936 under a contract held with NHS England. The National General Practice Profiles states that 48% of patients registered at this Practice are White, 11.92% are Black, 26.18% are Asian, 4.75% are mixed and 9.16% are other. They also have two satellite branches Woodcroft Medical Practice and Willow Court Surgery.
Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 6th decile (6 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the practice, the context the practice was working within and how this impacted practice delivery. We assessed all quality statements across the safe, effective, caring, responsive and well-led key questions. Where relevant, further commentary is provided in the quality statements section of this report.
SAFE: Incidents had been reported and investigated; lessons learned were used to inform practice. We did not see evidence of completed fire risk assessments across the three sites, despite the practice stating these had been undertaken previously, we did not see evidence of this. Following the CQC visit, fire risk assessments were completed for all sites. Leaders had not always made sure staff had received mandatory training, clinical supervision or annual appraisals to support high-quality care. Infection prevention and control (IPC) risks to people using the service was identified in the last IPC audit but risks were not mitigated while awaiting resolution with the landlord.
We identified good practice in the management of medicines associated with abuse and dependence risks and medicines used to treat insomnia and anxiety. However, improvements were needed in the monitoring of blood thinning medicines and medicine used to treat epilepsy and migraine.
EFFECTIVE: People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving practices. Staff made sure people understood their care and treatment to enable them to give informed consent.
CARING: People were treated with kindness and compassion and were involved in their care and treatment. The National GP Patient Survey results showed 84% of respondents stated that during their last appointment, the healthcare professional was good at treating them with care and concern. In addition, 91% of respondents said they were involved as much as they wanted to be in decisions about their care and treatment.
RESPONSIVE: People were involved in decisions about their care. The practice provided information people could understand. People knew how to give feedback and were confident the practice took it seriously and acted on it. There was robust monitoring of complaints by the practice, with evidence of timely review and appropriate actions taken.
WELL-LED: Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible and supportive. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Leaders worked with the local community to deliver the best possible care and were receptive to new ideas.
We did find some areas for improvement in relation to governance. For example, during our on-site visit, we found gaps in training files and there was a shortfall with the oversight of staff recruitment records. The practice acted after our visit to put this right, and we saw evidence that staff were now all up to date with their required training.
We found breaches in relation to safe care and treatment and good governance.