Sefton Ave Surgery Also known as Mulberry Medical Practice

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 practice leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

Overall, 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. Staff understood their roles and responsibilities. However, we found that aspects of staff management and the overall organisation were not sufficiently effective and required improvement.

The practice did not always have effective systems and processes to ensure good governance in accordance with the fundamental standards of care. For example, the management of infection control, medicine management, recruitment checks, staff training and supervision.

At our last assessment, we rated this key question as Good. At this assessment, the rating has changed to requirement improvement.

The provider was in breach of regulation in relation to good governance.

This service scored 62 (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 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.

Staff told us they felt well supported by their leaders. The practice had a clear business development plan and a defined vision for its future direction. This outlined key priorities and actions to support long‑term sustainability while continuing to deliver high‑quality, patient‑centred care. These focused on enhancing practice provision, improving patient experience, and strengthening staff engagement and wellbeing. The practice demonstrated a forward‑looking approach through the development of aspirational plans and ideas focused on enhancing practice provision and improving patient experience.

The practice had inclusive leaders who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge and experience to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders at the practice were approachable and responded to any concerns raised. They provided examples of support provided and how leaders involved them and listened to their ideas. We saw the leadership team worked with other practices within the PCN and wider ICB and engaged in developing primary care services. The practice had carried out a staff survey to gather staff feedback and support improvement. Feedback was further supported by initiatives such as employee of the month and staff newsletters, helping to promote staff engagement and a positive working culture.

Although we found areas of concern during the inspection, leaders were quick to address them and implement solutions to the issues raised with them.

The practice fostered a positive culture where people felt they could speak up and their voice would be heard.

There was a whistleblowing policy, Freedom to Speak up (FTSU) policy as well as a bullying and harassment policy in place.The practice had a designated freedom to speak up guardian that staff could contact if there were any concerns. Leaders were also available and receptive to hearing about the concerns staff may have had. The practice promoted a positive and supportive culture where people felt they could speak up and their voice would be heard. Staff were aware of how to raise concerns, contribute ideas and give feedback. Leaders had an open-door policy for all staff.

The practice valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued. Leaders held regular meetings where staff could raise concerns. Staff had completed training in equality, diversity, and inclusion and were aware of supporting people with protected characteristics such as age, gender, religion, or disability.

The practice did not always have clear responsibilities or systems of accountability. Governance arrangements were not always effective in supporting the consistent management and delivery of high‑quality, sustainable care.

Staff could access all required policies and procedures. Leaders held regular practice meetings with staff, during which they discussed clinical concerns. Leaders clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

Leaders had not ensured that staff always followed prescribing policies and evidence-based guidelines. Systems were not always effective in identifying, mitigating and monitoring risk. The processes in place did not ensure that risk assessments related to the premises were completed. Leaders and staff had not followed their own policies in relation to infection control, recruitment checks, staff training.

We identified gaps in governance systems for monitoring mandatory training compliance, although the provider submitted additional evidence following the inspection, some training certificates were dated after the on‑site visit.

There were gaps within staff recruitment records. We did not see evidence of relevant qualifications for certain clinical staff, and suitable reference checks were not consistently available. For example, evidence of a reference for a member of staff was submitted and dated following the on‑site visit.

The management of clinical supervision did not provide adequate assurance of appropriate oversight. While a clinical supervision policy was provided, the supporting documentation did not provide assurance of clinical supervision. A member of staff we spoke with told us they had regular meetings; however, they did not receive a structured one to one clinical supervision.

Staff we spoke with knew who the relevant lead person was for areas such as safeguarding and infection control. Staff took patient confidentiality and information security seriously.

Following the inspection, the provider had taken steps to improve governance and provided CQC with updates to evidence action taken.

The practice understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The practice was part of the local primary care network. The PCN was established in April 2025 and consisted of two member practices. The provider collaborated with the other practice within their PCN to offer extended access and vaccination programmes, physiotherapy services, smoking cessation, phlebotomy, spirometry, ECG, social prescribing.

The practice had a Patient Participation Group (PPG); however, membership numbers were low and previous attempts to increase participation had not been successful. Despite this, the practice had an active PPG chair and provided evidence of recent engagement, including a meeting held with the chair. The practice had taken steps to rebuild the group and had started work to identify and engage patients through its registration process.

The provider was committed to continuous learning, innovation and improvement across the organisation and local system, but this was not always well-supported by their systems and processes. The practice could not always demonstrate a culture that consistently supported effective learning and development. The practice did not have full oversight to ensure all staff were up to date with mandatory training requirements.

The practice was a teaching and training practice. They supported medical students training to be doctors, student nurses and salaried GPs. The practice provided evidence of clinical and non-clinical audits which actively contributed to safe, effective practice and research.

The practice did not have a system in place to record and learn from incidents related to downtime of the total triage system. Without recording and reviewing these incidents, opportunities for organisational learning and service improvement may be missed.