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.

At our last assessment we rated this key question as requires improvement. At this assessment the rating has changed to good.

Leaders had the skills, knowledge and experience to perform their roles. Leaders shared their vision and supported staff in their roles. Governance processes operated effectively. There was a clear framework for governance meetings. Leaders focused on improving patients’ safety and shared learning following an incident.

Staff knew and understood the provider’s vision and values. Staff felt respected, supported and valued by leaders. Staff felt they could speak up.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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.

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff were able to tell us the service’s values, which were kindness, integrity, teamwork and excellence. Staff applied the services’ values in their work.

Leaders had developed strategies appropriate to the service and were embedding them. For example, there was a strategy to reduce restrictive practice. The vision was to create a therapeutic and person-centered environment where restrictive practice was minimised and only used when clinically justified. There were clear objectives in place to help achieve this.

Leaders developed a new vision on safeguarding, which included embedding a safeguarding culture. The vision, strategy and expectations were shared with staff through training. Leaders communicated their vision and values effectively.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders supported staff to perform their roles. Staff received regular supervision and most staff had yearly appraisals. Where there were gaps in appraisal compliance, leaders were able to explain gaps and a plan was put in place to address this.

Leaders were able to explain their strengths and challenges. For example, leaders told us there were pressures in the system to make decisions about patient observations. Leaders made decisions that focused on the safety of the patient. This meant that leaders understood the treatment and support patients needed and reflected the service values in their decision making.

Staff told us leaders were visible, approachable and they felt supported. A staff member told us the leadership was good and if they had ideas, they could discuss and implement them. Most patients told us that leaders were approachable.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Leaders created a positive culture where staff felt they could speak up. Staff told us they could raise concerns with leaders and there was an open culture.

There was a freedom to speak up policy, which was last reviewed in December 2025. This gave information on how to raise a concern and who to raise it with.

Patients were able to give feedback in regular community meetings and through patient surveys. Most patients felt they were able to raise concerns. One patient told us they would not feel able to raise concerns with staff.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders valued diversity in the workforce. Staff told us there was an equality, diversity and inclusion champion and lead. Staff told us diversity was celebrated through events such as Pride celebrations. Staff felt supported by leaders.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Leaders had oversight of clinical risks and ensured there was a clear framework for clinical governance meetings. Meetings included agenda items such as risk for escalation, emerging challenges, themes, physical health and safeguarding.

Leaders had oversight of operational issues and ensured there were regular operational governance meetings. These meetings included complaints, compliments, duty of candour, investigations, environment and staffing.

Leaders had oversight of service and environmental improvements that were needed. Leaders ensured audits were completed. Where audits were non-compliant an action tracker was put in place. For example, where environmental issues were identified there was an action in place to address this. This included actions such as a contractor reviewing damaged door frames.

Leaders ensured there was a business continuity plan in place. This gave details of appropriate contacts and a plan for events that could have an impact on the running of the service.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Leaders worked in partnership with stakeholders to ensure services worked seamlessly for patients. For example, NHS trusts block booked beds at Potters Bar Clinic. Leaders told us they had weekly meetings with the trusts to review this.

Leaders attended a provider collaborative forum, where safeguarding and learning from national incidents was discussed. This meant that leaders were engaging with other providers to share information, learn from incidents and increase patient safety.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Leaders focused on continuous learning and improvement. Leaders ensured after action reviews were completed following an incident. Learning was identified following incidents and was shared with the team.

Leaders ensured that staff were aware of safeguarding processes. Staff were sent regular emails regarding safeguarding with a scenario. This supported with general learning and knowledge on safeguarding.

Leaders were able to identify and implement changes to improve safety for patients. For example, changes were made to incident reporting forms. Staff were given an example of an incident reporting form, to ensure that forms were completed correctly.

Leaders had a site improvement plan in place. This included plans to refurbish the wards, with progress on actions documented. While leaders were aware of site improvements that were needed, this was still in progress.

Potters Bar clinic were members of Quality Network for Working-age inpatients wards (QNWA). This meant leaders were sharing best practice and learning from feedback.