Sefton Ave Surgery Also known as Mulberry Medical Practice

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support.

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

People were supported to understand their care and treatment, and staff made sure people understood their care and treatment to enable them to give informed consent. The practice supported patients to live healthier lives and supported carers.

This service scored 67 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Results of the National GP Patient Survey showed 80% of patients felt their needs were met during their last GP appointment. 84% of patients felt the healthcare professional they saw had all the information they needed about them during their last appointment.Both these results were below local and national averages.

People felt involved in assessment of their needs and felt confident that staff understood their individual and cultural needs.Leaders and staff told us the practice used codes and alerts on the patient’s record to highlight special needs such as the requirement for longer appointments or for a translator to be present. Staff checked people’s health, care, and wellbeing needs during health reviews.Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber. Staff at the practice appeared to be aware of the needs of the local community.The practice worked with Age UK to provide social support to patients.

During our onsite assessment we identified that one of the branch sites did not have step-free access, which may limit accessibility for patients with mobility issues. The practice was aware and patients could access appointments at the other two sites when needed.

As part of the assessment, a number of set clinical record searches were undertaken by a CQC GP specialist advisor. A sample of the records of patients withlong-term health conditionswas checked to ensure the required monitoring was taking place. These searches were visible to the practice.

We reviewed asthma patients and we identified a total of 10 patients with asthma who have been prescribed2 or more courses of rescue steroids in the last 12 months. The search identified that patients were appropriately recalled, reviewed, and followed up according to need. Asthma reviews were documented, and ongoing management plans were in place. Patients were monitored effectively, with appropriate follow‑up arrangements to support safe and effective long‑term condition management.

The practice used integrated national guidance and local medicine optimisation pathways to support medicines monitoring. However, patients’ needs were not always assessed, and care was not always delivered in line with legislation and clinical standards. For example, information had not always been recorded on patient records to ensure that it was safe to continue prescribing and that the patients received appropriate care and treatment.

We found that patients with long‑term conditions were monitored appropriately. We reviewed the care of patients with asthma and diabetes and found that management and monitoring were effective. Patients received regular diabetes reviews in line with recommended guidance. There were appropriate recall and follow-up systems in place, and reviews were clearly documented in the clinical records.

We found mixed compliance with medicines safety monitoring. While there was evidence of appropriate communication of risks for certain medicines that can harm an unborn baby, gaps were identified in relation to valproate and topiramate monitoring, which are used to treat epilepsy and migraine. Required risk assessments and documentation did not consistently meet MHRA guidance. Medication reviews for patients taking multiple medicines (polypharmacy) were not carried out in a structured way and were inconsistent.

We spoke with the provider about our findings, which they acknowledged and have taken steps to strengthen its approach. Work is underway to implement a more structured medication review template for patients with polypharmacy, ensuring consistent documentation.

The practice worked well across teams and services to support people. Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support.

The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. There were systems in place to support the effective assessment and treatment of patients with more complex needs.

Leaders told us the practice participated in the local Primary Care Network (PCN), where they collaborated on shared service delivery. The practice employed Additional Roles Reimbursement Scheme (ARRS) staff, a program that funds PCNs to hire multidisciplinary teams to support general practice. The practice had employed a newly qualified GP, pharmacy technician, first contact physio, GP assistant and social prescriber.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. The practice supported people to live healthier lives and where possible, reduce their future needs for care and support.

The practice told us they focused on prevention and early intervention to help reduce future care needs. Staff identified health risks such as end-of-life needs, patients at risk of developing a long-term condition and those with caring responsibilities, frailty, carer responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity, and were able to discuss with the assessment team how they did so.

Staff including clinical pharmacists, healthcare assistants and the nursing team were all involved in managing and monitoring long term conditions and patients with learning disabilities.

The provider submitted clinical audits they had carried out to improve outcomes for patients. Findings from audits were shared with staff to help identify further areas for improvement in outcomes for patients.

The latest information from the UK Health Security Agency (UKHSA) showed the practice was performing below the national targets for the number of children immunised against various infectious diseases (01/04/2024 –31/03/2025). The practice had not met all immunisation targets, meeting 1 out of 5 targets for childhood immunisations. Reviewed data showed low cervical screening uptake among younger patients (25–49 years, under 70%) and older patients (50–64 years, under 80%). However, unverified data demonstrated recent improvement towards national targets for both patient cohorts. The practice had protocols in place to improve uptake of screening and immunisation. The practice sent reminder messages to patient who had not responded to invitations to book appointments to have a smear test or immunisations.

Patients were advised chaperones were available. The provider had a chaperone policy and staff who acted as a chaperone had completed training.

The practice told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.

We reviewed staff training records which demonstrated staff had completed training to support their knowledge of the Deprivation of Liberty Safeguards (DoLS), but not all staff were up to date with the mental capacity act training.

Staff we spoke with understood Gillick competency and there was a process to ensure young adults had control over their own privacy and the amount of parental involvement in managing their care and support.