The Care Quality Commission
  • Doctor
  • GP practice

Sefton Ave Surgery Also known as Mulberry Medical Practice

Overall: Good read more about inspection ratings

3 Sefton Avenue, Mill Hill, London, NW7 3QB (020) 8959 1868

Provided and run by:
Dr Anthony Tobias

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Sefton Ave Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Sefton Ave Surgery, you can give feedback on this service.

26 October 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced focussed, desk based inspection at Sefton Avenue Surgery on 26 October 2016. We found the practice to be good for providing safe services and it is rated as good overall.

We had previously conducted an announced comprehensive inspection of the practice on 17 September 2015. As a result of our findings, the practice was rated as good for being effective, caring, responsive and well led, and requires improvement for being safe, which resulted in a rating of good overall. We found that the provider had breached Regulation 12 (2) (a) (f) (g) (safe care and treatment) and Regulation 19 (Fit and proper persons employed) (1) (a), (3) (a) of the Health and Social Care Act 2008.

The practice wrote to us to tell us what they would do to make improvements and meet the legal requirements. We undertook this focussed inspection to check that the practice had followed their plan, and to confirm that they had met the legal requirements.

This report only covers our findings in relation to those areas where requirements had not been met. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Sefton Avenue Surgery on our website at http://www.cqc.org.uk/location/1-540525527.

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

  • Emergency equipment and medicines were monitored properly and safely; and were appropriate for their intended purpose.

  • An automated external defibrillator (AED) had been purchased and was readily accessible.

  • Recruitment files for locum staff were complete and provided assurance that staff were suitable for employment.

  • The practice had reviewed and implemented recommendations outlined in its 2014 Legionella risk assessment and report.
  • Appropriately signed patient group directions (PGD’s) were in place and reviewed regularly in line with national guidelines.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

5th August 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Sefton Avenue Surgery (also known as the Mulberry Practice) on 5 August 2015. Sefton Avenue Surgery is the main surgery of the Mulberry Practice. Mulberry Practice operates two satellite surgeries, Woodcroft Medical Centre and Willow Court Surgery (this practice merged in January 2015). These were not visited as part of this inspection. Overall the practice is rated as Good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider must:

  • Ensure all emergency equipment and medicines are monitored properly and safely and appropriate for their intended purpose. Review monitoring arrangements for emergency medications to ensure they are robust.
  • Assess the risks associated with not having an automated external defibrillator (AED) (a portable electronic device that automatically diagnoses the life-threatening cardiac arrhythmias of ventricular fibrillation and ventricular tachycardia in a patient)
  • Ensure that all recruitment files for locum staff are complete to ensure staff are suitable for employment.

Importantly the provider should:

  • Review and implement recommendations outlined in the Legionella risk assessment and report.
  • Ensure that all patient group directions (PGD’s) are reviewed regularly in line with national guidelines.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice