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 rated this key question as good. At this assessment the rating has remained as good.

Care plans were person centred. Staff worked alongside other agencies and services to support young people with their care and treatment. Staff made sure information was available for young people and listened to their concerns. Staff made adjustments where needed, to support young people. Staff helped young people to prepare for important life changes.

However, we found there had been information breaches. Learning was identified following these incidents.

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 3. The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Staff ensured care plans were person-centred. For example, young people’s care plans referenced their likes and dislikes. There were also individualised plans in place for risks identified. For example, where a young person had an autism diagnosis, there was a plan in place to support their individual needs.

In care records we reviewed we found young people had positive behaviour support plans in place, which were individualised and written in the first person. This showed that staff involved young people when developing these plans.

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 and external services in care where appropriate. We saw that young people were supported to attend appointments in the community to manage their health needs. For example, we found that a young person had an appointment for a diabetic eye screening.

Young people had access to school onsite. Most young people told us school was good and were positive about their experiences. However, 1 young person told us they didn’t feel respected by teachers at the school.

We scored the service as 2. The evidence showed some shortfalls. The service did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff sent out daily update emails to family and carers. However, 1 family member we spoke with told us they had received information about the wrong young person on more than one occasion. Managers had identified learning from this and shared with staff.

Staff made sure that information was available to young people. We did a tour of the wards and found information was available on the safeguarding team, how to make a complaint or compliment, laundry timetable, community meetings and solicitors’ information.

Staff told us they were able to access interpreters when required.

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 young people’s concerns. There were regular community meetings, where young people could give feedback. Community meetings involved young people and staff from the multi-disciplinary team, including school staff. The agenda for community meetings included the environment, relationships on the ward, restrictive practice, food and other relevant topics. Progress on actions was clear. For example, a young person raised that a bedroom needed painting and this was completed.

Leaders investigated complaints. Over the last 6 months there were 10 complaints relating to Opal and Jasper ward and most complaints related to clinical care. There was a complaints policy in place. In January 2026 the service received 8 compliments, and most compliments were related to attitude of staff.

Staff made sure young people knew how to access an Independent Mental Health Advocate (IMHA). Most young people told us they knew how to access an advocate. There was a patient advocate on the wards.

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 made reasonable adjustments for young people. Staff created communication passports to support young people when needed. Staff told us they communicated with young people differently depending on their needs. For example, staff told us they communicated by writing things down or explained things in a different way to enable better understanding.

Staff told us they had equipment and tools to support sensory needs. For example, staff used slime, memory boxes and ice to support young people where risk assessed. There was also a separate microwave on the ward for hotties (teddies that can be made warm by microwaving) to support young people’s sensory needs.

Leaders made sure that young people had access to appropriate care. There was adequate medical cover and there was a medical emergency response procedure in place.

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 young people 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 prepared for discharge early in treatment. We reviewed discharge data and found that all young people had a forecast discharge date and details about the planned discharge. For example, we found that the multi-disciplinary team were seeking advice on a discharge to an adult rehabilitation ward for a young person. This meant that staff worked collaboratively with other services to prepare young people for discharge.

However, 1 young person told us they did not know what their plan was for discharge.