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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question as requires improvement. At this assessment the rating has remained. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. We found a breach of regulation 12 (safe care and treatment).

Some areas of the environment needed refurbishment and maintenance. Care planning was not always person centered and care plans were not always written in the patient’s voice. Patients told us they did not always get a copy of their care plan. Risk assessments did not always have an appropriate management plan in place for risks identified and were not always completed soon after admission. The environment was not always safe.

However, leaders ensured there was a culture of safety and learning was identified following an incident and was shared with the wider team. Staff ensured that essential information was gathered prior to admission and completed referrals to external agencies where appropriate. Leaders had taken action to address sexual safety concerns that were identified during the last CQC inspection. There were enough skilled staff to support patients. Medicines were safe and met patient needs.

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.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Leaders investigated and identified learning from incidents. In the last 6 months 569 incidents were recorded across ruby and crystal wards. This included incidents of self-harm, aggression, incidents relating to physical health and medication errors. There was evidence in care records that appropriate actions were taken following an incident.

Leaders ensured lessons learned were shared with the wider team following an incident. For example, there was an incident of a patient absconding. Immediate actions were taken, which included following absconding protocols. Lessons were learned regarding observations and communication. An action plan was also put in place following the incident. Lessons learned were shared across services, when themes of incidents were identified. Learning from investigations and incidents meant that they might be prevented from happening again.

We requested duty of candour records for the last 6 months. There were 3 incidents that had resulted in duty of candour. Duty of candour means health and social care providers must be open and honest about the care they give and use mistakes as opportunities to learn and improve. Duty of candour training compliance was 100%.

Staff had a good understanding of when to report a concern, incident or near miss and knew how to report them. Appropriate action was taken by managers when a concern was reported.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Managers ensured that safe systems, pathways and transitions were in place. The service's referral and admission processes ensured that all essential information about the patient was received prior to admission. There was an admissions standard operating procedure for staff to follow when admitting a patient. The process included requesting section papers and completing an admission checklist to ensure all steps of the admission process were completed. This meant that admission processes were safe.

Leaders ensured there was an inclusion and exclusion criteria in place. Exclusion from the service included patients with an acquired brain injury, dementia or recent sexual aggression. This meant that processes were in place to make sure that patients were appropriately admitted to the service.

Staff liaised with external specialists where appropriate. For example, in 1 care record we reviewed, we found a patient had received support for diabetes management. This meant patients were supported to manage their physical health needs.

Staff ensured patients had continuity of care on discharge from the service. Patients were referred to external agencies, such as rehabilitation outreach services to prepare for discharge. We also found staff worked alongside community mental health teams. Discharge summaries were sent to external teams, which included the patient’s history, presentation on admission, medications prescribed, information from ward rounds and risk assessment. This meant that discharge processes were safe.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Leaders had taken action to address sexual safety concerns following our last inspection, where it was found that not all staff were aware of sexual safety incidents. There was a sexual safety policy in place, which was issued in May 2025. Staff were given training on sexual safety, which included a discussion of incidents that had taken place on the wards, professional boundaries and action to take, where there was a sexual safety concern. There was a sexual safety and response flow chart in place, which provided staff with information on steps to take where there was a concern. Compliance for sexual safety training was 100% for bank and permanent staff.

Staff ensured that patients were protected from abuse. The service had a comprehensive safeguarding log in place, which detailed safeguarding actions taken after an incident. For example, where there were disclosures of historical abuse, appropriate actions were taken. This included supporting the patient to report to the police and external safeguarding referrals. Managers also held meetings following a safeguarding incident to discuss concerns and identify appropriate actions. Whilst reviewing the services safeguarding log, we found evidence that the service’s internal social worker met with patients following a safeguarding concern. This meant that safeguarding processes were embedded.

Safeguarding adults and children training compliance was 96%. Staff we spoke with knew the safeguarding processes and were able to explain what they would do if they had a safeguarding concern.

There was a safeguarding adults policy, which was last reviewed in August 2024. There was a safeguarding children policy, which was last reviewed in January 2024. Policies were comprehensive and outlined processes for staff to follow when a safeguarding concern had been identified. This included alerting the safeguarding lead and referring to the local authority.

Most patients we spoke with told us they felt safe on the ward. Some patients told us they did not feel safe due to other patients on the ward.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 6 risk assessments and risk management plans during our inspection. We found 3 care records had risk assessments completed on the day of or soon after admission. Risk assessments did not always include an appropriate management plan for risks. For example, in 1 care record a patient had a risk of falls. We did not see a management plan in place to mitigate risk of falls. This means that patients could be at risk of avoidable harm. However, following our inspection the provider ensured all risk assessments were reviewed.

Staff did not always involve patients in care planning. In the care records we reviewed, we found clinical language was used and we did not always see the patient’s voice was reflected. Care plans were not always completed soon after admission. In the care plans we reviewed, 3 were not completed soon after admission. This meant that patients were not always involved in decisions about their care and treatment goals were not clear for all patients.

However, staff worked with patients to ensure they received treatment to meet their physical health needs. For example, we found evidence of a patient needing support with foot health. Staff supported the patient by making a podiatry appointment. This meant that staff understood patients’ needs and involved external agencies and services to support patients when needed.

Staff used restrictive practice as a last resort. We found evidence in care records of de-escalation being used in the first instance. Restraint was used in cases where de-escalation had failed. This meant that staff worked with patients to support them with their needs.

There were no seclusion rooms on Ruby or Crystal ward. Managers told us that patients would be referred to a psychiatric intensive care unit (PICU) if they could not be safely managed at Potters Bar Clinic.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Staff did not always ensure ligature risks were mitigated. We did a tour of Ruby and Crystal ward. During our tour of Ruby ward, we observed a games console in the quiet room, which was not locked away securely. This was a potential ligature risk to patients and was not included on the ward’s ligature risk assessment. We discussed this with staff during our inspection and this was immediately locked away.

Leaders did not always make sure the environment was maintained. Areas of the wards needed maintenance and refurbishment. We observed some areas of the wards looked worn. For example, mesh on some windows in communal areas was discoloured. The floor in the communal area on Ruby ward was uneven. Staff told us this had been reported. Some patients reported that their showers were cold. Some chairs on Ruby and Crystal wards were torn and needed to be re-upholstered or replaced. Leaders told us there was a plan in place to re-upholster chairs and chairs were being sent away in batches. We also found other environmental improvements had been made, such as new mattresses had been ordered, a night light had been installed to avoid waking a patient during observation and air conditioning had been installed. This meant that leaders had oversight of environmental improvements that were needed.

There were ligature risk assessments in place for Ruby and Crystal ward, which were last reviewed in January 2025. There were ligature heat maps in the staff office on both Ruby and Crystal ward. Staff were able to tell us of ligature risks on the wards and what mitigation was in place. There were ligature cutters in the staff offices, medicines room and in the kitchen.

Leaders ensured equipment was in place to make the environment safe. There was closed-circuit television (CCTV) in communal areas and corridors to mitigate risk in areas that were out of sight. There were convex mirrors in corridors and areas where sight was limited. We observed a safe door in a patient’s bedroom, to allow staff to maintain safety and privacy. Staff had personal alarms and radios. There were call bells in patient bedrooms and bathrooms.

Leaders had ensured that equipment was tested and safe for use. We found that equipment to monitor physical health had been serviced and was next due a service in May 2026. Electrical equipment had also been tested and was compliant.

We observed cleaning taking place during our inspection. There was a cleaning schedule in place and evidence of regular cleaning taking place.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Leaders ensured there were enough qualified and skilled staff to meet patients’ needs. The multi-disciplinary team consisted of a hospital director, 4 consultants, 2 ward doctors, ward managers, deputy ward managers, nurses and healthcare assistants. There was a therapies team, which included psychologists and occupational therapists. There was a designated safeguarding lead and a social worker. There were housekeeping, catering, administration and maintenance staff in post. At the time of our inspection there were vacancies for the following roles; service lead, personal assistant, maintenance and reception staff.

Managers ensured that staff had completed training appropriate for their role. Both agency and bank staff completed an induction. Overall mandatory training compliance for all staff was 95%.

Managers ensured that staff received regular supervision. Overall compliance for supervision was 95%. Overall appraisal compliance was 91%. Leaders told us appraisal compliance had been impacted by staff leave and changes within the leadership team. However, all outstanding appraisals had been scheduled.

Leaders ensured recruitment of staff was safe. Staff had disclosure and barring service (DBS) checks in place.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Staff ensured the environment was mostly clean. We observed some parts of the environment, such as mesh on windows were discoloured. On Ruby ward there was a cupboard with a coffee machine on top. The inside of the cupboard needed to be cleaned. Staff ensured this was cleaned following inspection. One patient told us that the washing machine did not clean their clothes very well. Following our inspection, we found evidence that the washing machine had recently been repaired.

Leaders ensured environmental audits were completed. However, there were some areas of non- compliance in environmental audits. For example, door frames had been identified as damaged and some furniture needed replacing. There was an action log, which showed action that had been taken and ongoing work that needed to be completed.

There was an infection prevention and control policy in place, which was last reviewed in June 2024.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The multi-disciplinary team regularly reviewed prescription and administration records. We saw evidence that medicines were administered in line with relevant mental health act ‘consent to treatment’ authorisations where needed.

Medicines were stored safely and securely, including controlled drugs and other medicines liable to misuse. We saw evidence that staff conducted medicines assessments on admission including medicines reconciliation.

People had regular physical health monitoring, especially those prescribed high risk medicines. We saw evidence that staff used different communication methods to engage with people living with learning disabilities and autism to ensure that they understood their medicines.

Decision making process were in place to ensure that people’s behaviour was not controlled with excessive use of medicines.

An external clinical pharmacy service was used to provide advice on safe and effective use of medicines. The pharmacist visited the wards once a week, however, staff told us that they did not usually attend the multidisciplinary team meetings (MDT). People discharged from the service or going away for a weekend break, were supplied with discharge medicines to take away (TTAs).

However, the pharmacy service did not provide a TTA supply service for people going on home leave, rather this was being dispensed in house by nursing staff. We saw a sample of TTA medicines labels and instructions staff used when preparing discharge medicines, and these did not include cautionary labels. This does not meet the dispensing standard expected as compared to when TTAs were supplied by a pharmacy.

Staff told us that they conducted medicines audits. The pharmacist attended monthly governance meetings and produced medicines optimisation reports.

Rapid tranquilisation (RT)was used as a last resort and staff actively worked to use alternative person-centred ways to de-escalate without the need to administer RT. We saw evidence that when people were given RT, they were appropriately monitored.

When PRN (‘when required’) medicines were used the reason for their use and what else had been tried first was clearly recorded on the daily electronic care records.