Potters Bar Clinic

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

During this inspection we found breaches in well led relating to governance processes and oversight by managers.

The rating of well led had decreased and was rated as requires improvement.

We inspected all 7 quality statements. Managers did have effective oversight of some issues and required further time to embed improvements at the service. This related to staff awareness and understanding of sexual safety, indications of a closed culture forming and issues surrounding the environment. However, the service had a stable management structure in place. Auditing processes were well embedded in the service. Staff were encouraged and supported to develop their learning and skills. Leaders were involved and visible and gathered staff views on improvement, service feedback and ensured staff received regular supervision.

We have not awarded this service a score for Well-led.

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

Some patients fedback that some staff were rude, did not show compassion towards them, were dismissive, and did not want to engage with them. We were concerned that this may indicate a poor culture was forming. We raised this with the provider, and they were not aware of these issues around culture. The initial assurance received was not clear as to how the alleged poor culture was to be resolved. Managers have now 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. However, we were not assured managers had implemented this at the time of the inspection and further work was required to ensure this was fully embedded.

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. Compliance with sexual safety training was 78% and managers were working on this to improve their staff’s compliance and understanding. Further work was required by the provider to ensure all staff had an understanding and received training on sexual safety at the service. Managers also informed us they did not have a local sexual safety policy.

However,Leaders ensured there was a vision, mission and values which were shared with staff at induction. Staff completed training in equality and diversity.

Staff said they felt respected, valued and supported.

The provider had a strategy, a new wellbeing launch which promoted the importance of physical, emotional, social, financial and workplace wellbeing. This strategy included short- and long-term goals with a plan of how to achieve them.

Patients and carers were involved in decision-making about changes to the service.

At the time of the inspection the hospital director was recently new in post. Staff spoke highly of them. The hospital director demonstrated a passion for and plans to consider and include the experience from the patients' perspective.

Leaders had adequate understanding of the services they managed. They were aware of the key challenges and risks and were open in sharing them.

Staff felt supported by managers and told us that the hospital director was both approachable and engaged well with staff and patients. Leaders were visible within the service and had the experience, capacity, capability, and integrity to ensure that the organisational vision could be delivered, and risks were well managed.

Staff spoke positively about the introduction of deputy ward managers that had been introduced over the last 12 months.

Staff demonstrated a collaborative approach that actively involved the patients in the care process.

Leaders told us that the service promoted an open and honest culture and had a Freedom to Speak Up Guardian in place.
Leaders informed us that a whistleblowing procedure was established, and staff were aware of it. However, no staff members had utilised the whistleblowing process.
Staff were aware of the term ‘freedom to speak’ and what this meant, they were able to explain how they would access freedom to speak up information if they needed it. Staff said they felt able to speak up and were listened to and where there was learning this was shared amongst staff.

The service worked towards an inclusive and fair culture by improving equality and equity for people who worked there. The service had a diversity, equality and inclusion lead for the region who worked on site as a practice development nurse as well as the quality improvement mentor.

The service employed a diverse team of staff from international backgrounds. Employment practices promoted equality of opportunity. Managers said the service did not discriminate against staff from minority groups. Staff did not raise any concerns about discrimination.

Leaders had ensured reporting of racial abuse against staff was prioritised. Leaders had identified a theme of racial abuse in recent incidents. In response to this leaders arranged for a neighbourhood community officer from the police to talk to all wards around racism and assault. The patients had an opportunity to talk to the police.

Although the service had clear responsibilities, roles, systems of accountability and governance processes to manage and deliver care and treatment, managers required further time and work to make improvements at the service. We identified concerns regarding the environment, a poor culture and sexual safety concerns at the service which managers did not have full oversight of. The provider was aware of the concerns we raised and had started to take measures to address these following our inspection. However, the provider required more time to implement and embed these improvements.

Clinical governance meetings were held for the whole hospital. The meeting was chaired by the hospital director. These meetings covered standard agenda items including key areas of concern, good practice, risk management and lessons learnt, safeguarding, and quality improvement projects.

Managers used dashboards routinely to monitor performance targets.

Team meetings and clinical governance meetings followed a clear structure.

Regular audits and checks were conducted to review compliance and quality of work.

The risk register for the hospital covered both adult and children's wards. This included ten risks. These were: staffing vacancies, the risk of harm to a patient (including self-harm and absconding), Increase in incidents of ingestion, and risks relating to the environment in the local area around the hospital. The risk register included a score for the severity of each risk, actions being taken to address the risk (including immediate mitigation) and timescales for completing those actions. For example, the hospital is located within 500 metres of the M25, this could be a self harm or suicide risk. To mitigate this patients are risk assessed prior to being granted leave with a specific focus on their risk of absconsion or potential suicide to maintain safety.

Commissioners told us there were clear and open lines of communication, however sometimes incidents were not always reported as swiftly as they could be which led to delays in letting families and carers know.

Patients had regular contact with the service’s independent advocate and could request to see an Independent Mental Health Act advocate for issues relating to the Mental Health Act.

Managers understood their duty to collaborate and work in partnership with other services. They shared information and learning with partners and collaborated for improvement. For example, in working towards discharge with patients and their carers’, addressing their specific needs and preferences.

The compliance lead for the service completed 5 quarterly submissions to its funders containing relevant information.

Commissioners and the advocate told us that staff and leaders were open and transparent, and worked well in partnership with them. They described the staff team as professional and prompt across the board, from the senior leadership team (including medical staff) through to administrators.

Discharge planning formed a part of the weekly review meetings and community teams attended weekly ward rounds for their patients placed at the service, wherever possible.

Stakeholders told us there were quarterly contract reviews with senior finance colleagues, the provider and other Patient flow colleagues from Oxford Health that were well organised and well represented.

Occasional face to face visits took place when required so that patient flow staff could monitor the quality of care and the surroundings at the service.

Staff told us they would work alongside other services or specialist services such as drug and alcohol rehabilitation providers when required.

Managers did not ensure staff demonstrated sufficient learning from sexual safety incidents. Although learning from incidents was shared across sites, Managers had not identified the training needs of their staff on sexual safety. A quality improvement initiative has been planned to improve this. However, this improvement project had not started at the time of the inspection.

Innovations were taking place at the service. The hospital was working towards The Quality Network for Working Age Mental Health Services Accreditation (QNWA).

The provider had encouraged positive learning environment. The safeguarding lead and managers regularly reviewed incidents, identified actions, and conducted thorough investigations involving patients.

Reflective practice sessions were held with staff, and debrief sessions were held when needed. Learning was shared with the staff team at regular handover and other multidisciplinary team meetings. Managers encouraged staff to reflect on what could be changed, and collective problem-solving. Leaders encouraged staff to speak up with ideas for improvement and innovation. Staff told us there was a sense of trust between leadership and staff.

The hospital director told us of plans for Quality improvement (QI) initiatives. These were based around co production with the patients.

The provider had a framework for introducing Quality Improvement methodology focused on continuous learning, innovation, and improvement across the organisation. The hospital director was looking to embed Quality Improvement methodology and encourage creative ways of delivering equality of experience, and quality of life for patients.