Mather Avenue Surgery

Updated 11 December 2023

The Mather Avenue Surgery is located in Liverpool at:

584 Mather Avenue

Allerton

Liverpool

Merseyside

L19 4UG

• The provider is registered with CQC to deliver the Regulated Activities;
• Diagnostic and screening procedures
• Family planning
• Maternity and midwifery services
• Surgical procedures
• Treatment of disease, disorder or injury.

The practice is situated within the NHS Cheshire and Merseyside Integrated Care System and delivers General Medical Services (GMS) to a patient population of about 9,000. This is part of a contract held with NHS England.

The practice is part of SWAGGA[KJ1] [DO2] Primary Care Network (PCN) which is a collaboration of 16 GP Practices geographically aligned and working together to improve patient care. SWAGGA PCN has a weighted patient population of approximately 105k patients with a diverse population and diverse patient needs.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 4th lowest decile (4 of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is, 93% White, 3% Asian, and 4% Other.

There is a team of 5 GP partners and 4 associates supported by a team of 3 part time nurses and 3 health care assistants. The clinical staff are supported at the practice by a team of reception/administration staff, medical secretaries, a practice manager and a deputy.

The practice is open 8am to 6.30pm Monday to Friday with extended hours appointments until 8.30pm and out of hours appointments are available via 111 when the practice is closed. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided locally by the primary care network, where late evening and weekend appointments are available. Out of hours services are provided by NHS111.

Updated 11 December 2023

We carried out an announced comprehensive inspection at Mather Avenue Surgery on 24 October 2023. verall, the practice is rated good.

Safe - good

Effective – good

Caring - good

Responsive - good

Well-led - good

The practice was rated good at the last inspection in 2016.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Mather Avenue Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection because of aged ratings and to follow up on concerning information received.

We inspected the key questions of safe, effective, caring, responsive and well-led.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A shorter site visit.

Our findings

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 found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm. All concerns highlighted as a result of the remote part of our inspection process were dealt with immediately and before the site visit.
• Patients received effective care and treatment that met their needs. Where concerns were raised as a result of the remote part of our inspection process these were dealt with immediately and before the site visit.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
• Staff well-being was at the heart of the ethos of the practice.

Whilst we found no direct breaches of any regulations, the provider should:

• Take more timely action in response to all safety alerts as demonstrated in their ongoing action plan.
• Improve the recording of information and documentation including that relating to safeguarding, recruitment and medication reviews.
• Take action to address monitoring and follow up action required for patients with long term conditions as already highlighted and addressed in their ongoing action plan.
• Continue to improve uptake for cervical screening and immunisations.
• Continue to evaluate, monitor and improve patient access.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care