Potters Bar Clinic

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last assessment we did not assess this key question. At this assessment the rating is good. This meant people’s needs were met through good organisation and delivery.

Staff worked in collaboration with other services to ensure care met patient’s needs. Staff worked alongside services, such as community mental health teams to support patients. Staff ensured information was available to patients. Staff helped patients with communication, cultural and spiritual support. The service treated concerns and complaints seriously, investigated them and learned lessons from the result.

However, care plans were not always person-centered. Some care plans were not written in the patient’s voice and clinical language was used. Patients did not always receive a copy of their care plan.

We have not awarded this service a score for Responsive.

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

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

Staff did not always ensure care plans were person-centred. Care plans were personalised to patient needs, however they were not always written in the patient’s voice. For example, we found clinical language was used in some care plans we reviewed. Patients told us they were not always given a copy of their care plan. This meant that care plans were not always person-centred.

Staff took patients’ needs and preferences into account. For example, some patients had health and care passports in place. This documented patient preferences and needs, how to support them and things that were important to the patient.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Staff involved external agencies in care where appropriate. For example, we found care co-ordinators and external agencies were invited to ward rounds. Patients were supported with discharge and referrals to external agencies were made where needed. This meant care was joined up.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff ensured that information was available for patients. There was information available on sexual safety, safeguarding, community meetings and how to make a complaint. Staff told us that information could be given to patients in more accessible formats where required. For example, information could be printed in larger font or on coloured paper to support patient’s needs. One family member we spoke with told us their loved one had been given easy read information.

There was a comprehensive data protection and confidentiality policy, which was last reviewed in August 2025.

Staff had completed training in information governance. Training compliance for both permanent and bank staff was 96%.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

Staff listened to patients’ concerns. There were regular community meetings, where patients could give feedback. Patient surveys were completed on admission, during admission and on discharge. This meant that patients were able to provide feedback about their care.

Leaders investigated complaints appropriately. There was a complaints policy in place. In the last 6 months there were 5 complaints relating to Ruby and Crystal ward. Complaints related to clinical care, communication and staff conduct. Where complaints were partially upheld, learning was identified. For example, where gaps were identified in communication learning included facilitating support from an independent mental health advocate (IMHA). From October to December 2025 the service had received 15 compliments. A theme in compliments received was positive attitudes of staff.

Staff made sure patients knew how to access an Independent Mental Health Advocate (IMHA). There was information about advocacy on the wards. Most patients told us they knew how to access an advocate.

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

Staff ensured mobility needs of patients were met. There was a lift to enable disabled access to the wards. Staff told us there were appropriate aids available to support disabled patients, such as shower chairs.

Staff made sure patients had access to appropriate care. There was adequate medical cover and an appropriate emergency response procedure in place. This meant that patients could access treatment when they needed.

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who were most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Leaders used data to identify health inequalities and gathered feedback from patients and their families. This meant that leaders listened to information about people who were most likely to face inequality.

Staff had completed training in equality, diversity and inclusion. Training compliance for permanent and bank staff was 99%. Leaders were embedding Patient and Carer Race Equality Framework (PCREF).

There was a comprehensive equality, diversity and inclusion policy in place.

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future.

Staff supported patients to prepare for important life changes. Staff made sure relevant professionals were involved in care. For example, a patient was referred to an outreach team to support on discharge. Discharge summaries were sent to external services. This meant that staff ensured all relevant professionals were involved in care.