Potters Bar Clinic

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed all 8 quality statements. At our last inspection we rated this key question as requires improvement. This remains unchanged. During this inspection we found breaches in relation to safeguarding service users from abuse, staff understanding of sexual safety and closed cultures and issues with timely repairs to the environment. However, the environment was clean, staff had robust recruitment processes with up-to-date mandatory training and there was a good incident reporting culture at the service.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

Although learning from incidents was shared across sites, not all staff we spoke to were aware of recent sexual safety incidents. Staff we spoke with did not have an understanding of sexual safety incidents and could not demonstrate learning as a result of these. We only observed learning from 1 incident of sexual safety where an adult patient had exposed themselves to a CAMHS patient. Although managers had reflective tint applied to the windows to prevent future risk, staff we spoke to were not aware that the tint was added to the windows due to the sexual safety incident.

The service had up to date incident reporting processes for internal incidents. We reviewed evidence before and after our assessment that demonstrated the service understood its responsibility to submit statutory notifications. We reviewed the incident log dated between September 2024 to February 2025 where 778 incidents were reported. Of those 778 incidents, the highest reports type of incidents were 482 incidents violence and aggression, 80 incidents were in relation to self-harm and 77 were in relation to security concerns. Leaders told us there was a high number of incidents due to the high acuity of the patient group.

Staff raised concerns and reported incidents, serious incidents and near misses in line with policy. All staff knew what incidents to report and how to report them. We reviewed the service's incident log to confirm this.

Although staff were not always aware of sexual safety incidents, staff received feedback from investigations of other types of incidents, both internal and external to the service. A recent example of learning following an incident was where a patient had concealed a blade in the back of their phone case. Following this incident staff now have a process in place where they check phone cases on admission and when returning from leave. A lessons learned poster has also been shared with staff.

Incident investigations confirmed that staff were debriefed and offered support after a serious incident. Leaders investigated incidents where appropriate. Reports were thorough and addressed all points raised.

Community meeting minutes did not always demonstrate follow up of actions and outcomes. However, following our inspection the provider is using a new template to record and follow up the actions from community meetings.

We sought feedback from people who commission the beds, they fedback that incidents were not always reported in a timely manner and this meant that external stakeholders did not have an up to date picture of the risk.

Ward round invitations to community teams were not always sent consistently.

However, stakeholders told us that the team were open to feedback regarding patients care and treatment plans, and made necessary adjustment following consultation where required.

Another patient flow team told us they attended weekly reviews with the responsible clinician who was always on time, considerate and inclusive of patients, families and carers whilst protecting confidentiality. Discharge planning formed part of the weekly reviews and community teams attended weekly ward rounds for their patients when they received an invitation.

Stakeholders found managers to be professional and open to feedback provided.

Stakeholders attended quarterly contract reviews with senior finance colleagues. The provider and other patient flow colleagues and feedback that these were very well organised and well represented.

The service's referral and admission processes ensured that all essential information about the patient was received to ensure the patient's needs could be met safely. There was a clear criteria of people they would and would not accept. For example, they did not take people with complex physical health needs. We reviewed 6 care records which evidenced multidisciplinary collaborative working and patient views. Risk assessments and treatment plans were updated and reflected current risks and needs. However, Approved Mental Health Professional (AMHP) reports were missing from 3 out of 6 peoples care records.

Staff told us about comprehensive discharge planning meetings where family, the MDT and external people involved in the patients' care attended. Staff said that there could be delayed discharges due to issues securing accommodation. Staff ensured that patients discharge to their local mental health teams were managed safely.

The inspection took place partly due to concerns we had received about sexual safety at the service. When we inspected the service, staff did not have a full understanding of sexual safety and could not demonstrate how they would protect patients, we were not assured that staff could protect patients from potential sexual safety risks. We fed this back to managers during our visit. Leaders had identified that their staff did have training needs around sexual safety. Compliance with sexual safety was 78% and staff were working on this to improve their compliance and understanding. Managers also informed us they did not have a local sexual safety policy, however there was an Elysium wide sexual safety policy.

Feedback from patients did not demonstrate that all staff were ensuring all patients were free from abuse. As part of the inspection patients fedback that some staff were rude, that they did not show compassion towards them, did not want to engage with them, were dismissive and raised 1 concern of another patient being threatening towards them. This indicated a poor culture was forming which we raised with leaders. Managers provided assurances on all concerns we referred to and had developed an action plan to improve the culture at the service including closed culture training for staff. We reviewed the safeguarding log alongside the incident log, which was up to date and included details about safeguarding incidents. However, it did not detail whether safeguarding incidents were being investigated internally or by the local authority. During the inspection we spoke with staff including managers, doctors, nurses, healthcare assistants, members of the multidisciplinary team, and administrative staff. Staff knew how to make a safeguarding referral and who to inform if they had concerns. The provider had systems and processes in place for staff to follow to protect patients from abuse and neglect.Managers ensured the service had a comprehensive local safeguarding procedure which included good working relationships with other agencies, including the local authority. Managers held morning meetings where any safeguarding incidents were shared, discussed, and managed with onward referrals to the local authority and protection plans put in place. Staff received training on how to recognise and report abuse, appropriate for their role and kept up to date with their safeguarding training. Overall, the providers average compliance with safeguarding training level 1 to 3 was 96.8%.

Staff told us they were planning a safeguarding day for the hospital, this included involving patients to create safeguarding posters with the Occupational Therapist as part of a competition. The aim was to create a positive culture about safeguarding.

During the inspection, we generally observed positive interactions between staff and patients that were patient, calm, inclusive and warm in nature. Patients interacted with various members of staff and had a member of staff with them continuously. Observations were made of positive engagement and activity that would be of benefit to the patient. For example, a patient was trying to read a written document but did not understand it, a staff member was observed taking the document, reading it and passing it back before talking to the patient to help them understand what it said.

Community meetings took place regularly on the wards and we saw posters displayed on wards giving information about safety, advocacy, patients' rights and how to make a complaint.

We reviewed 6 care records, which demonstrated patient and family involvement. However, Patients told us they were not always involved in their care planning or were given a copy of their care plan. We spoke with 6 people, 2 said they had not received a copy.

People's risk assessments were completed on admission, and we saw that they were updated at various points throughout their admission. Observation boards were clear, indicating each patient's observation level. Staff we spoke with showed a good understanding of the management of risk and reducing restrictive practice. Staff spoke about using restraint and seclusion as a last resort and gave several examples of interventions they would use to manage and de-escalate situations. Staff said they knew patients, and this helped them to support patients and prevent potential incidents from escalating. Staff regularly updated care plans and risk assessments following incidents. We saw examples where risk assessments had been updated following incidents of restraint that included patient views.

Staff demonstrated an understanding of the management of risk and were aware of the procedures to follow in the event of an emergency or if they needed further support to manage risks to people. Staff followed procedures to minimise risks where they could not easily observe people. There were closed circuit television (CCTV) cameras in all the communal areas internally, including the meeting rooms. CCTV was not monitored 24/7 but was used to review incidents. When someone was in their bedroom, staff went to the room to check on their well-being. Staff followed the provider's policies and procedures when they needed to search people's belongings or their bedrooms to keep them safe from harm.

The hospital held quarterly restrictive practice group meetings. We viewed minutes between September 2024 and November 2024 where all areas of restrictive practice were presented, any themes identified and actions to be taken. However, there were some blanket restrictions in place. For example, patients could not access the ward kitchen. Although patients had access to a kitchenette in the communal area, we saw meeting minutes from the restrictive practice group considering how to support access to the kitchen for patients.

Restrictive practices were also discussed at community meetings with patients. For example, some patients were requesting charging leads which was raised at the meeting. As a result, patients were allowed their chargers within a certain length, and after risk assessment their charging leads in their bedroom. Staff ensured that patients could access advocacy.

There was no use of seclusion or long-term segregation, patients requiring this would be referred to a different setting.

We saw evidence that the service was monitoring whether observations were being completed appropriately through audits.

Following the inspection in December 2019 the provider had a breach in relation to the maintenance and cleanliness of environment on all wards. This included completing repairs in a timely manner. During this inspection, we found that the service had made some improvement in cleanliness although there were still some issues with repairs.

We observed and patients' fedback some concerns regarding the environment. Two out of 7 patients told us the ward was too hot. Managers provided inconsistent information regarding issues relating to temperature control at the hospital. We were told that the boiler required repair on Ruby ward and the flooring was being replaced on the ward. We observed fans and heaters present during our visit which staff had said were provided to manage the regulation of temperature whilst the repairs and refurbishment were taking place. However, when we later asked for further information in relation to this, managers had told us the boiler had been repaired prior to our on-site visits. It was not clear why portable heaters were still present on the ward.

Although patients were generally satisfied with the environment and equipment on the wards, some patients raised concerns that the space was small with restricted access to the shared garden. Overall, patients said they could access the garden.

Patients had access to the garden 7 times a day between 0700 and 2100, although there was flexibility on access in between these times.

At the time of assessment, the garden was unkempt. There was high fencing around the garden and a lockable gate that had graffiti on the inside of it, there was also remains of an old basketball net/hoop on one side of the garden. Work had clearly been done on a composite gazebo for the patients to use in the centre of the garden. Left over building materials and a large rock or piece of concrete had been discarded in the area between the main building and the garden, near to the gate leading to the outside of the hospital which made the garden look untidy and unkempt.

Each patient had their own bedroom, which they could personalise. However, the décor was tired, and the rooms were a little dark. The hospital had plans to improve the lighting and add night lights to the rooms. Bedrooms all had ensuite facilities. Renovations were ongoing whilst we visited the site. Whilst patients could personalise their rooms, we only saw one who had chosen to do so.

The ward layout allowed staff to observe most parts of ward. Managers completed regular audits of the environment which included blind spot audits. We reviewed a site improvement plan which included installation of a new CCTV system to ensure staff could review blind spots. The provider planned to include cameras in the garden where currently there was none.

Clinic rooms were equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. However, the size of the room did not allow for an examination couch.

Staff completed and regularly updated risk assessments of all areas.

Staff could not observe all areas directly, so fitted mirrors were used in communal spaces to enhance monitoring and ensure patient safety.

Staff had easy access to alarms and patients had easy access to nurse call systems. Call buttons were installed throughout the ward. The service provided alarms for staff and visitors. Some members of staff also carried a radio. Patients could access drinks and snacks. Following risk assessments, patients could use ward or mobile phones on the wards.

The ward kitchen was locked and not accessed by patients. Fruit was consistently accessible to patients along with drink making facilities.

The service had produced a `heat map' showing the location of high, medium and low risk ligature areas.

Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the patient group using the service.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff and leaders worked together effectively to provide safe care that meets people’s individual needs.

The induction comprised of 35 training courses relevant to the staff roles and the patient needs. An electronic dashboard monitored mandatory training and alerted staff when they needed to update their training. The compliance lead also had oversight of this dashboard and would contact staff where they needed to update or carry out training.

The service had enough nursing and support staff to keep patients safe. Ruby ward had capacity for 13 patients and Crystal ward had capacity for 12 patients. Both staff and patients agreed that there were always sufficient staff on the ward.

There were appropriate staffing levels at the service. Data provided by the service identified that there was a total of 79 staff at the service. Staffing comprised of nurses, healthcare workers, an administrator, support workers, therapists, education, occupational therapists, a social worker, psychology, catering staff, housekeeper and maintenance staff. There were some vacancies at the service, however the service met staffing requirements through some use of bank and agency. The service had enough daytime and night-time medical cover and a doctor available to go to the ward in an emergency. Each ward has a responsible clinician, and there was 1 ward Doctor shared between both wards. For out of hours, a resident medical officer had a room on site to be able to attend quickly.

The overall vacancy rate was low, this meant that use of bank and agency staff was low. However, the service still occasionally used temporary staff to cover short-notice absence such as sickness. However, the service had 6 nursing vacancies as of February 2025.

The staff turnover has decreased over the last 12 months and was currently at 14.62%.

The ward manager could adjust staffing levels according to the needs of the patients. Additional staff were assigned to the wards when there were high levels of acuity.

However, people told us they did not always have regular one-to-one sessions with their named nurse.

Patients rarely had their escorted leave or activities cancelled. There were sufficient staff on the ward to facilitate these activities.

Staff shared key information to keep patients safe when handing over their care to others. Nurses and health care assistants attended a hand over meeting at the start of each shift. Other members of the multidisciplinary team had a daily hand over meeting.

Each new member of staff had a full induction to the service before they started work. All new staff attended a 3 week-long induction programme, facilitated by their own training facility off site. The hospital arranged new staff to be able to access online training, and to receive an orientation to the ward. They then spent time shadowing experienced staff before they were fully incorporated into the staff numbers.

Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge.

Staff were supported through regular, constructive clinical supervision of their work.

Managers also supported permanent staff to develop through yearly, constructive appraisals of their work. Up to February 2025, 196 of 211 staff (92%) had received an appraisal. Staff told us they had supervision monthly. 224 of 229 (97%) staff were up to date with their supervision.

The hospital’s policy stated that staff should receive managerial and clinical supervision each month, and this was taking place. Staff said they found these sessions helpful. During supervision sessions, staff typically discussed their health and well-being, safeguarding, clinical care and training and development needs. Managers made sure staff attended regular team meetings. Staff held team meetings each month. During these meetings staff discussed lessons learned from incidents, admissions and discharges, safeguarding, security matters, Advocacy, training, health and safety matters and administration relating to the ward.

The occupational therapists timetabled a variety of therapeutic activities Monday to Friday with activities led at weekends by the healthcare assistants. These included self soothe, ward cooking, pet therapy, psyche soma, gardening, life skills, arts and crafts, community integration, music, pampering and life skills.

We saw that some food was not stored in line with food safety standards. We told managers about this who rectified this whilst we are onsite. Storage date labels were missing from a lot of food items in the fridges. This meant the service had not assessed and managed the risk of infection or detected and controlled the risk of infection spreading.

There was mould in the sealants in some of the ensuite bathrooms. However, the ward areas were mostly clean, tidy and had good furnishings. Wards kept up-to-date cleaning records that demonstrated that the ward areas were cleaned regularly. Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date. The service followed infection control policy, including handwashing. The service carried out regular clinical audits, which included infection control.

Staff had completed food hygiene and food safety training. There was a comprehensive food safety, management and hazard analysis policy in place, which provides guidance around safe food storage. However, this was not always followed. Following our inspection the provider is using a new template to include monitoring of fridge checks.

We visited both Ruby and Crystal wards. We spoke with 2 ward managers, 1 deputy ward manager and 2 nurses who administered medicines. We observed medicines being administered on both wards, reviewed medicines policies and procedures, prescription charts and associated care records for 10 patients. We reviewed instances of rapid tranquilisation used on the wards and associated care records relating to these.

The provider had processes in place to ensure people received their medicines safely and as prescribed, however these were not always followed. We saw one example where medicines were not given as prescribed, and records did not reflect what had happened. However, the service appropriately managed the incident in line with policies and procedures, ensuring the patient was safeguarded. People were given their medicines in accordance with the Mental Health Act consent to treatment authorisations.