During an assessment under our new approach
Date of Assessment:14to15 October 2025. Potterells Medical Centre is a GP practice which delivers services to approximately 16,839 people under a contract held with NHS England.
The National General Practice Profiles states that the ethnic make-up of the practice area is 73% White, 11% Asian, 8% Black, 4% Mixed and 3% other ethnicity. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 8th lowest decile (8 of 10). The lower the decile, the more deprived the practice population is relative to others and the higher the decile, the less deprived the practice population is relative to others.
This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
We looked for evidence that people were protected from abuse and avoidable harm. We found the practice had systems in place to support safe care, with evidence of proactive clinical oversight, effective medicines management, responsive safeguarding arrangements and a positive learning culture. Staff generally recognised and responded appropriately to deteriorating patients and there was good multidisciplinary working and continuity of care.
However, there were several governance and oversight gaps, including in significant event management, safeguarding registers, staff training, recruitment records, medicines processes and safe environments. Inconsistencies in documentation, monitoring systems and the sharing of learning across staff groups reduced assurance that risks were consistently identified, recorded and mitigated.
The provider was in breach of the legal regulation in relation to safe care and treatment and the service has been rated requires improvement for providing safe care and treatment.
We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this. The practice delivered effective care through proactive management of long-term conditions, use of evidence-based guidance, strong multidisciplinary working and tailored approaches to meet population needs, particularly for students and vulnerable groups. Clinical oversight was generally robust, with positive patient outcomes and feedback reflecting responsive and personalised care. However, there were some limitations, including minor delays in follow-up, inconsistent dissemination of learning, gaps in documentation, variable uptake of screening programmes and training compliance and some concerns around prescribing and consent processes.
We looked for evidence that the service involved people and treated them with compassion, kindness, dignity and respect. A total of 242 feedback responses were received, of which 228 were positive and 14 were negative, indicating a consistently high level of patient satisfaction with the service. The practice demonstrated a strong caring culture, with staff consistently treating patients and colleagues with kindness, compassion and respect, supported by positive patient feedback and survey results. Patients felt listened to, involved in decisions and treated as individuals, with responsive care, good support for independence and access to services. The practice promoted privacy and dignity, although some concerns were raised regarding confidentiality at reception. Staff wellbeing and teamwork were generally well supported, with a positive working environment, although some mixed views about management support indicated areas for improvement.
We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination. We found the practice demonstrated a person‑centred and responsive approach to care, with strong collaboration across services and tailored support for diverse population groups, including students, care home residents and vulnerable patients. Care was generally well coordinated and integrated, with good continuity and access, supported by proactive initiatives such as total triage, multidisciplinary working and targeted support for specific communities. Patients reported high satisfaction with care and involvement in decisions and systems were in place to promote equity, independence and access to information. However, there were some gaps, including inconsistencies in communication, complaints management, accessibility of information and equitable access for certain groups, as well as variability in patient experience and follow‑up processes, which reduced assurance that services were consistently responsive across all areas.
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. We found the practice demonstrated a clear vision and positive, inclusive leadership culture, with strong partnership working, community engagement and a focus on continuous improvement and innovation. Leaders were approachable, experienced and supported staff wellbeing, contributing to high staff retention and a stable workforce. The service engaged proactively with local partners, including the university, Primary Care Network (PCN) and Patient Participation Group (PPG), to shape services and respond to population needs. However, there were governance and oversight gaps, including in training, documentation, risk management, recruitment processes and the consistency of strategy awareness across all staff. While future planning and workforce sustainability had been recognised, these plans were not yet fully developed.
While governance and oversight gaps were identified, these were primarily operational and not reflective of leadership intent or culture. Leaders had recognised these risks and were taking steps to address them. Overall, strong leadership, a positive culture, effective partnership working and a clear strategic direction outweighed these gaps, supporting a rating of good for well-led, including strong collaboration with the University of Hertfordshire to deliver integrated and responsive services.