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Inspection carried out on 03-05 December 2019

During a routine inspection

Potters Bar Clinic offers Child and Adolescent Mental Health Services (CAMHS) Tier 4 low secure services for young people aged 13 to 18 with a wide range of disorders and complex needs.

The hospital also has two acute wards for adults of working age, one for male and one for female patients.

We rated Potters Bar Clinic as good because:

  • We examined all care records for patients and young people. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating and de-escalating violence and aggression.
  • Ligature risk assessments were available on all of the wards along with heat maps which are diagrams which show the high-risk ligature points. Staff undertook regular ligature risk assessments of the wards.
  • Staff developed comprehensive care plans for each young person and patient that met their mental and physical health needs.
  • We examined six weeks of the duty rotas on each of the wards and found that the number of nurses and healthcare assistants matched the expected numbers on all shifts. Bank and agency staff members were block booked and were familiar with the wards young people and patients. All bank and agency staff had received appropriate training as well as an induction to the ward prior to their allocated shift.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well. Managers made sure that staff could explain patients’ and young peoples’ rights to them. Mental Health Act training figures were at 91% at the time of inspection.
  • Staff treated patients and young people with compassion and kindness. We saw discreet, respectful and responsive interactions.
  • Staff supported the young people with activities outside the service and made sure young people had access to education throughout their time on the ward. There was a school on site and teachers also attended the wards to provide one to one education to patients.
  • Managers were resilient and had a strong drive for improvement. There was good oversight of safeguarding, incidents, observations and notifications to external bodies across the hospital. Management of risk and risk registers had improved significantly.
  • Staff that we spoke with felt respected, supported and valued. They felt the service promoted equality and diversity and provided opportunities for career development.


  • Ward re-decoration was necessary on the adult acute wards as some areas were shabby, dirty and needed deep cleaning. The ward redecoration and kitchen refurbishment was on a scheduled log for completion.Some basic maintenance issues had not been dealt with in a timely way.
  • Managers monitored compliance with mandatory training. Most training had a compliance rate of over 75%. However, safe administration of medications was low at 52%. Infection control (level 1) at 68% and level 2 at just 50%. Suggestions, ideas and complaints, and the management of violence and aggression had a 71% compliance rate.

Inspection carried out on 18-19 June 2019

During an inspection looking at part of the service

We did not rate this service because this was a focused inspection. We inspected this service because at our last inspection in February 2019, we had concerns about this provider. Following the inspection in February 2019, we took action to prevent further admissions to the wards for children and young people at this service. We also told the provider to submit information to the Care Quality Commission over a number of months to show what action they had taken about the concerns we raised.

  • We were not assured that staffing levels were at a safe level to manage the children and young people on the wards. There was a high number of agency and bank staff used at the service and we were not assured they had received the appropriate levels of specific training in child and adolescent mental health issues.
  • We were not assured that agency staff received regular supervision.


  • We were assured that the provider had made improvements in ensuring permanent staff received regular supervision.
  • We saw improvements in how staff recorded risk assessments for patients who used section 17 leave. The provider had embedded a new system for staff to assess how patients felt before leaving the ward on leave, and what contingencies were in place should the leave break down.
  • We were assured that the provider had improved how staff updated patients' risk assessments following incidents. This included an alert system in the electronic record so that staff cold see, at a glance, what the risk behaviours were of patients in their care.
  • We were assured the provider had improved how they monitored and evaluated incidents. Three independent senior managers reviewed all incident forms and senior manager took action where necessary to investigate incidents and make recommendations to improve practice. Where required, the provider had consistently notified external agencies about incidents.
  • The provider had taken action to update and improve ligature risk assessments and mitigation for risk.Staff working on the wards, knew how to identify ligature risks in each area of the wards, and knew how to mitigate risks in their day to day work with patients.
  • The provider had completed a review of how enhanced observations of patients was carried out by frontline staff. We saw an improvement in how staff completed enhanced observation records.

Inspection carried out on 20 - 21 February 2019 and 28 February 2019

During an inspection looking at part of the service

We did not rate this service because this was a focussed inspection.

  • We were not assured that patient safety was a priority. Managers did not ensure that safeguarding processes and procedures were adhered to by staff. We found a number of occasions when staff had not reported incidents to external bodies as required. This included safeguarding concerns, and serious patient injury. Incident forms were not always completed accurately and had not been signed off by appropriate senior staff. Staff were unable to provide examples of lessons learned from incidents. Many young people self-harmed even when on constant observations with multiple staff observing them.
  • Staff did not fully recognise risks associated with anticipated events and emergency situations. Five out of seven patients did not have an initial risk assessment completed within 48 hours of admission as per the provider’s policy. We found that in some instances, staff had not completed a risk assessment for several weeks. Completed risk assessments were not updated by staff following incidents.
  • Managers had not identified all potential ligature anchor points on the ward ligature risk assessments. The ligature risk assessments had the same mitigations regardless of the risk or location. For example, the mitigation for ligatures in patient bedrooms stated that there was CCTV. There was not CCTV in patient bedrooms.
  • The leadership and governance did not always support the delivery of high quality person-centred care. We found repeated poor application of the safe and supportive observation and engagement policy. We found evidence of the emergency responder being allocated to carry out patient observations. If the alarms sounded, the staff member would either not attend, or they would leave their patient on enhanced observations unsupervised.
  • There had been numerous and repeated occasions of staff shortages. Although the provider was able to staff wards at a level they had assessed as being safe, at times there were too few staff to meet all care needs of the patients.
  • People were at risk of not receiving effective care and treatment. We found multiple instances where the provider did not follow their section 17 leave policy. We found gaps within the pre-leave risk assessment forms. Leave forms were not sufficiently detailed. Six out of 14 nurses and health care workers knew the location of the Mental Health Act administrators but not who they were.


  • The ward complied with guidance on eliminating mixed-sex accommodation. 
  • All staff received an induction to the service. Each staff member then had some time on their allocated ward, on a supernumerary basis. When bank and agency staff were used, we saw evidence of a bank and agency induction pack to familiarise themselves with the provider and ward.
  • The multidisciplinary team provided a range of care and treatment in line with National Institute for Health and Care Excellence guidance. Staff used recognised rating scales to assess and record severity and patient outcomes.
  • Four patients told us regular staff were respectful, caring and polite. We observed patients engaged with members of staff in a range of activities.
  • Staff told us leaders were visible on the wards and all staff knew who the senior management team were. Most staff said they felt respected, supported and valued by their colleagues.

Inspection carried out on 7 and 8 September 2017

During a routine inspection

We rated Potters Bar Clinic as good because:

  • Patients reported feeling safe on the wards.

  • The wards were clean, tidy and well maintained. Observation mirrors and closed circuit television were used alongside observation to maintain safety.

  • There were detailed ligature risk audits across the wards.

  • We observed staff to be passionate and motivated to meet the patients’ care needs.

  • Staff demonstrated a good understanding of patients’ individual needs, including care plans, observations and risks.

  • Staff completed comprehensive assessments for all patients following admission.

  • Staff were positive, supportive and caring in their interactions.

  • Staff undertook a risk assessment with every patient upon admission.

  • All wards had fully equipped clinic rooms with accessible resuscitation equipment and emergency drugs.

  • Cleaning records were up to date and demonstrated that staff regularly cleaned the environment.

  • There was good management of medication.

  • Routine physical health observations including, weight and blood pressure monitoring was taking place.

  • Staff demonstrated a good understanding of the Mental Health Act and Mental Capacity Act.

  • The Mental Health Act administrators had good oversight of the service. They provided daily input to the wards.

  • There were activities across the week including weekends.

  • There were robust processes in place for handovers, team meetings and sharing lessons learnt across the service.

  • Senior managers met every morning to discuss the service needs including referrals, admissions, discharge, leave, incidents and staffing.

  • Staff demonstrated the provider’s visions and values in their behaviour.

  • The provider had short term contracts in place with agency staff which increased consistency on the wards.

  • Staff consistently reported that managers were supportive and would listen and act on any concerns they raised.

  • The service employed a service user involvement representative that supported the patients’ voice.


  • Non-clinical staff were not receiving supervision.

  • Team meetings were recorded as group supervision on some wards. There were gaps in supervision records in staff files.

  • The wards relied heavily upon agency staff to cover their shifts.

  • Staff sickness was at 11%.

  • Compliance with mandatory training was low in some areas.

  • Care plans were not always holistic or recovery focused.

  • Complaint records were not always complete.