The Care Quality Commission
  • Doctor
  • GP practice

Mather Avenue Surgery

Overall: Good read more about inspection ratings

584 Mather Avenue, Allerton, Liverpool, Merseyside, L19 4UG (0151) 427 6239

Provided and run by:
Mather Avenue Surgery

All Inspections

16 november 2023

During a routine inspection

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

19 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Mather Avenue Surgery on 19 May 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • The practice was in the middle of a refurbishment programme. Some rooms had recently been refurbished but some patient facilities, including disabled facilities, were yet to be completed.

  • There were systems in place to mitigate safety risks including analysing significant events and safeguarding.

  • Patients’ needs were assessed and care was planned and delivered in line with current legislation.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice had a mixture of appointments available including an open access service every morning, telephone consultations and pre-bookable appointments.
  • Information about services and how to complain was available. The practice sought patient views about improvements that could be made to the service; including carrying out regular surveys and having a patient participation group (PPG) and acted, where possible, on feedback.

  • The practice team had a good skill mix with GPs having a range of clinical expertise. The practice encouraged career progression. Staff worked well together as a team and all felt supported to carry out their roles. The nurse clinician took a lead role for revalidation of nurses for Liverpool and had been nominated for the Nursing Times Lead Nurse award.

  • Some staff took an active role in various projects to improve lifestyle and health outcomes for the Liverpool population. For example, co-ordinating care between primary and secondary services for children suffering asthma.

There were outstanding elements of practice:

  • All urgent dermatology referrals under the two week rule received a second opinion from another GP to reduce any unnecessary referrals.

  • The practice had a diverse system for appointments including an open access system every morning and patients were offered a GP of their choice. The practice recognised that it was impractical to expect very young children to wait and had a designated time slot every morning for them to attend. All GPs, including the trainee GP, met after the open access clinic to discuss house visits to ensure continuity of care and any clinical queries. In the afternoon there was an on call GP who dealt with all urgent cases.

  • The practice dedicated one session a week for one of the GP partners to work on quality improvement. Quality improvements included, communications with patients, staffing, premises, medicines management and computing skills.

However, there were areas where the provider should make improvements.

The provider should:

  • Revise their complaints protocol to include the correct details of who patients should contact if they are not satisfied with the outcome of any investigation by the practice for a complaint.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

30 September 2013

During a routine inspection

We spoke with four people who used the service. People told us they had been able to make decisions about their care and treatment and they told us they had been treated with dignity and respect. Their comments included:

"I haven't got a problem with the practice."

"The only thing I would say is that it is sometimes hard to get an appointment."

We found that patients care and treatment was assessed, planned and delivered in order to meet the individual patient's needs. Care and treatment plans were fully documented and reviewed via a computerised records system. We also saw evidence that staff were inducted, trained and supervised appropriately.

We found the provider had effective systems in place for monitoring the quality of services. Regular audits were undertaken, there was an effective complaints process and regular patient satisfaction surveys were undertaken. A patient participation group functioned within the practice which gave patients the opportunity to give their views and offer feedback regarding the service.