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 good. At this assessment the rating has remained good.

Leaders ensured there was a culture of safety. Lessons were learned and shared following an incident. Staff knew when to report a safety concern and how to do this. Systems, pathways and transitions were safe. Admission processes were clear and there was an inclusion and exclusion criteria in place to ensure admissions were appropriate for the service. Staff knew how to safeguard young people from abuse. Appropriate safeguarding actions were taken following an incident or concern. This meant people were safe and protected from avoidable harm.

However, some areas of the environment needed maintenance. Infection prevention and control procedures were not always followed. Young people had physical health examinations in their bedrooms. This did not meet infection prevention and control standards.

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 had oversight of incidents and ensured appropriate action was taken following an incident. In the last two months there were 681 incidents across Opal and Jasper ward. This included incidents of self-harm, aggression, absconding and sexual safety. The incident log gave a summary of the incidents and the actions that were taken. We found staff took appropriate action. For example, where there was an incident of a young person having a seizure, actions included monitoring vital signs and neurological observations.

Leaders ensured lessons learned were shared with the wider team. Where an emerging theme of incidents was identified, procedures were put in place to safeguard young people and shared with all staff. For example, where staff lanyards were identified as a potential risk, leaders ensured that risk was mitigated and actions were put in place to safeguard young people. This included prohibiting lanyards on the wards and reviewing policies.

We requested duty of candour records for the last 6 months. 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. There was 1 incident that required duty of candour. Duty of candour training compliance was 100%

Staff knew how to report concerns, incidents or a near miss. Staff told us they would report any concerns to the nurse in charge, manager and safeguarding lead.

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.

There was an admissions standard operating procedure in place, which detailed the procedure that should be followed when a young person was admitted. In care records we reviewed, we found that admission procedures were followed. This meant that all essential information was gathered prior to admission and admission processes were safe.

Staff liaised with external specialists where required. For example, we found that a young person had a yearly asthma review completed. A domiciliary dental service attended to support young people with dental care. We also found that young people had appointments made with opticians and other services when needed.

Staff ensured that young people had continuity of care when they were discharged from the service. There was a discharge and transfer policy, which gave details of how to prepare a young person for discharge. In the care records we reviewed, we found evidence of discharge planning taking place.

Leaders ensured there was an inclusion and exclusion criteria in place. Exclusion criteria stated that young people with an eating disorder that required medical intervention should not be accepted. We found there had been incidents where a young person had required nasogastric feeding. Leaders told us that young people with a primary diagnosis of an eating disorder would not be admitted, however an eating disorder secondary to their diagnosis could be safely managed. We reviewed incidents where a young person had restricted their food intake and found appropriate action had been taken.

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.

Staff ensured young people were protected from abuse. There was a comprehensive safeguarding log in place, which gave details of safeguarding incidents and action taken by the provider. For example, where a young person had raised a concern about restraint, appropriate actions were taken. This included actions, such as informing their next of kin and social worker of the concerns.

There was a sexual safety policy, which was issued in May 2025. Staff were trained in sexual safety and there was a sexual safety and response flow chart, which provided staff with information on steps to take when there was a sexual safety concern.

Staff were trained in safeguarding. Training compliance for safeguarding adults and children was 96%.

Leaders ensured there was a safeguarding children and child protection policy, which was last reviewed in January 2024. The policy outlined clear steps to take where there was a safeguarding concern.

Staff knew how to make a safeguarding alert. Staff told us they would raise concerns with the nurse in charge, their manager and safeguarding lead.

Most young people told us they felt safe on the wards. One young person told us there were lots of staff, which made them feel safe.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 3 risk assessments and management plans during our inspection. We found that risk assessments were completed on admission and were reviewed regularly. Staff updated risk assessments following an incident and appropriate plans were in place to mitigate risk. This meant that staff were able to identify risks to young people.

Staff ensured care plans were reviewed regularly. Care plans were not always written in the young person’s voice, however it was documented in care notes that this was due to young people refusing to engage. Young people had crisis plans and positive behavioural support plans in place. In 1 care plan we reviewed, we found the young person’s autism diagnosis was referenced and support was offered accordingly. Care plans we reviewed stated the young person’s preferences and there was evidence of discharge planning. We observed a young person with a copy of their care plan. This meant that young people were involved in their care.

Restrictive practice was only used when necessary. We found that de-escalation was used in the first instance and restraint was used when other interventions did not work. Staff we spoke with were able to give examples of times they had de-escalated a situation. We found that restraint was used appropriately in care records. For example, we found a young person was restrained to administer a nasogastric feed.

There was a comprehensive reducing restrictive interventions policy in place, which included blanket restrictions. There were items that were prohibited on the wards. This included items, such as alcohol and illicit substances. Young people had access to a secure garden on request.

We observed the sensory room on Opal ward. There was a projector, sensory lighting and safety pods to meet young people’s sensory needs. This joined onto the seclusion room.

However, some young people told us restraint took place on the floor or in their bed. We discussed this with the provider and they told us that safety pods were available but were not always within reach when restraint needed to be used.

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.

Some areas of the wards needed maintenance. For example, the ceiling in the communal area of Jasper ward needed maintenance following a leak. Staff told us this had been reported and was due to be fixed when it had dried. We noticed an unpleasant smell on Jasper ward in the lobby. We asked staff about this and staff told us that the smell had started on the day of inspection. Young people did not raise this as a concern.

Young people told us environmental concerns could be discussed at community meetings. Two young people told us their showers were cold. We raised this with the provider during our inspection and leaders told us young people could be supported to shower in another room where needed until the issue was fixed.

Leaders ensured equipment was in place to make the environment safe. Staff carried radios and personal alarms. Young people’s bedrooms had call bells. This meant staff or young people could call for help when needed.

Staff ensured ligature risks were mitigated. We did a tour of Jasper and Opal ward and
found appropriate mitigation was in place to manage risks. For example, there were ligature heat maps in the main office of both wards. There were ligature cutters available in the main office, medicines room and kitchen. There was closed-circuit television (CCTV) in communal areas and corridors to mitigate risk in areas that were out of sight. There were anti-ligature fixtures and fittings. Staff were able to tell us ligature risks and mitigation. This meant the environment was safe.

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 the seclusion room on opal ward. There was a window for staff to safely observe young people, whilst they were in seclusion. Room temperature could be controlled from outside of the room, there was a toilet, washing facilities and a clock. This meant the seclusion room was a safe environment to support young people.

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 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 permanent and back 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 did not always manage the risk of infection. We observed blood in the window mesh of the seclusion room on Opal ward. Staff told us that they had attempted to clean it following an incident, however they were unable to get inside of the mesh to clean the blood. We raised this as a concern. Following our inspection, leaders provided evidence that the mesh had been cleaned. This mitigated the risk of infection.

Two young people told us blood was not always thoroughly cleaned following an incident. We discussed this during our inspection and leaders told us blood was cleaned as quickly as possible after an incident.

Staff told us physical health checks were completed in young people’s bedrooms. Staff told us this was a safer environment to complete physical health checks with young people. However, this meant there were infection control risks.

Most young people told us the environment was clean and regular cleaning took place on the wards. We observed cleaning of the wards during our inspection.

Leaders ensured environmental audits took place. There were some areas of non- compliance in audits. For example, an audit of Jasper ward found the laundry room was cluttered and not clean. Leaders had an infection control action tracker in place to manage areas of non-compliance. This evidenced actions that were taken when non-compliance was found. For example, young people and staff were reminded in community meetings to maintain cleanliness in the laundry room. This meant that leaders had oversight of infection control issues and were ensuring that issues were rectified.

There was an infection prevention and control policy in place, which explained decontamination and procedures for cleaning blood and body fluid spillage on floors and surfaces.

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.

Staff made sure that medicines and treatments were safe and met young people’s needs. Medication that was prescribed ‘when required’ (PRN) was not given for more than 7 days. PRN medications were reviewed regularly. In all medication charts we reviewed, we found that prescriptions had been signed by the doctor and medications prescribed were within British National Formulary (BNF) limits.

Staff ensured medicines were stored safely and securely, including controlled drugs and other medicines. This meant that processes were embedded to make sure medicines were stored safely.

We found evidence of consent to treatment in all medication charts we reviewed. However, staff did not always ensure prescriptions matched consent to treatment forms. We reviewed 5 medication charts. In 1 medication chart, we found that a patient was prescribed a medication and this was not specified as oral. However, on the consent to treatment this was documented as oral medication. This meant it was not clear for staff how to administer medication.