Potterells Medical Centre

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure patients care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. The practice was proactive in recalling patients for their long-term condition reviews.

We found there were systems in place to assess patients’ needs using the appropriate clinical tools, such as the tools to identify patients living with frailty and at risk of falls. A specialist frailty nurse from the primary care network (PCN) supported the practice and undertook home visits for the most vulnerable housebound patients. Some GPs had a specialist interest in dementia care. Reception staff used digital flags within the patient record system to highlight individual needs, such as longer appointment requirements or the need for translation services, to support personalised care.

Clinical staff used templates when conducting care reviews and people’s health, care and wellbeing needs were checked during health reviews and after hospital admissions. The practice told us these templates provided standardised coding, searches, templates and questionnaires, which supported consistent consultations and reduced the risk of missing key clinical information, contributing to safer and more effective patient care.

The practice also had effective systems to identify people with previously undiagnosed conditions; however, we also found some gaps in managing risk to patients. Our searches identified 6 patients as having potential missed diagnosis. We reviewed 5 of the 6 patient records and found no missed diagnoses were identified; however, 2 patients required follow-up for raised blood sugar results, whilst another patient required further investigation and another with delayed repeat testing. One patient had appropriate follow-up in place and 1 record was included in error. Overall, good clinical oversight was demonstrated, although minor delays in follow-up may increase clinical risk and impact patient outcomes if not addressed.

Our clinical record searches also found 45 out of 1,059 patients on the asthma register had been prescribed 2 or more rescue steroids in the past year due to an exacerbation of their condition. When we reviewed 5 of the 45 records, we foundgenerally, there was appropriate management of acute episodes, with face-to-face consultations supporting clinical need where identified. Most patients had a documented asthma review; however, 1 patient without a recent review continued to have rescue steroids on repeat, which may not have been appropriate. We also found rescue packs were frequently issued, with most of the patients having received multiple courses in the preceding 12 months, often during routine reviews or as repeat prescriptions; for example, 5 and 9 times for 2 different patients.

The practice demonstrated how they assessed and responded to the needs of their university student population. At the start of each term, an additional staff member was deployed in the registration area to explain how the NHS worked and supported students to register with the medical centre. Students with existing health conditions were offered a GP welcome appointment to ensure continuity of prescribed medicines and appropriate follow-up arrangements. Appointments were booked up to 48 hours in advance, in line with student preference, which reduced non-attendance rates.

The practice had established collaborative systems with the university’s occupational health department. Staff from the department supported students with mental health concerns, including those expressing suicidal ideation, by accompanying them to the service and facilitating referral for clinical assessment. Students who were not registered with the practice were offered immediate registration and a same-day appointment, bypassing the usual triage process to ensure timely access to care.

Although most of the feedback from people using the service was mostly positive, 1 negative feedback highlighted concerns regarding the assessment of need. One person reported that end-of-life medicines, including morphine, were prescribed without a clinical assessment or physical examination to confirm current need, indicating a potential risk to safe and appropriate care.

Overall, there was highly positive patient feedback which highlighted a highly responsive triage system, with 1 patient reporting a same day appointment within minutes of submitting an online request, leading to prompt diagnosis, treatment and recovery. Patients also described how clinicians identified red flag symptoms during routine reviews and acted swiftly to arrange urgent hospital care, with individuals crediting staff for early detection of serious illness.

Feedback from the care home reported residents with long-term conditions received regular reviews from the GP practice.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff had access to systems to support them to stay up to date with evidence-based guidance and legislation. GPs told us they attended regular updates and discussed changes to national guidance, including recent updates to asthma management. Clinicians also referred to recognised sources, such as the British National Formulary, to support safe prescribing in line with hospital advice.

Clinical meetings were reported to take place weekly, where national guidance was discussed; however, formal meeting minutes were not consistently maintained. The practice held around 10 protected learning sessions annually, including 8 in-house sessions funded by the ICB and 2 PCN-wide external events for all 4 practices, with external speakers and full staff participation.

Some evidence of meeting records was seen; however, these did not consistently demonstrate attendance or how learning was shared with staff who were unable to attend, reducing assurance that updates were disseminated across the whole team.

The practice also told us they believed in evidence-based healthcare whose success was reflected in their QOF achievement. The provider aimed to offer proactive care for patients, including long-term condition reviews; for example, diabetes and we saw evidence of this. The provider told us they had a strong tradition of annual visits to their housebound patients, which was going through a transition with the employment of a frailty nurse.

Clinical records we saw at both the main site and university branch site demonstrated care was provided in line with current guidance, as we found overall low numbers of overdue chronic disease monitoring and several examples of positive outcomes for patients who received evidence-based care. For example, our searches identified none of the 660 patients diagnosed with chronic kidney disease (CKD) stage 4 or 5 were overdue monitoring, indicating effective systems to ensure timely review and follow-up of this patient group.

We also found that no patients had been prescribed 12 or more rescue inhalers in the previous 12 months, indicating a positive outcome in asthma management, particularly within a student population. The practice reported that asthma care had been significantly improved over the past 18 months following an audit which identified high levels of high-dose prescribing. In response, the asthma team implemented a structured deprescribing approach through routine asthma reviews, reducing overall medicines burden. Where clinically appropriate, patients were transitioned to a Maintenance and Reliever Therapy (MART) regime, which uses a single combination inhaler for both maintenance and symptom relief. The practice told us their approach predated the November 2024 NICE guidance which advocated for the same and their MART prescribing is very high.

Our searches identified 66 patients from a diabetes register of 596. Five records reviewed showed all patients had appropriate average blood sugar monitoring in place or planned. Two results were recent, although 1 had not been followed up as intended. Two patients had received an annual review within 12 months, with 2 further reviews pending. Overall, follow-up of raised average blood sugar levels was effective, with minor delays identified in individual cases.

Monitoring of patients prescribed thyroxine was generally well managed. Of the 339 patients diagnosed with hypothyroidism, we found 6 patients were identified as overdue for monitoring based on searches. A sample of 5 patient records showed 1 newly registered patient and 3 patients were marginally overdue monitoring by 1 month and had received appropriate reminders.

Overall, the practice had an effective system for monitoring and follow-up, with a limited but significant area requiring strengthened oversight.

The service worked well across teams and services to support people and to ensure continuity of care, including where clinical tasks were delegated to other services.

They had a wide variety of inhouse staff ranging from Additional Roles Reimbursement Scheme (ARRS) roles, which are multidisciplinary staff employed through the primary care network (PCN) to expand workforce capacity and improve patient access. These included a clinical pharmacist and pharmacy technician for medicines optimisation, care coordinators to support patient pathways, a team of social prescribers and health and wellbeing coaches to address wider determinants of health. First contact physiotherapists were available for musculoskeletal conditions, a shared GP resource and mental health liaison support across both sites.

A community midwife held antenatal clinics at the practice and the practice also worked closely with the community mental health team and had access to a GP mental health liaison service. This service supported adults with mild to moderate mental health needs who required brief intervention beyond what could be offered within routine GP care but who did not meet the threshold for secondary care referrals. This provided additional support for vulnerable patients and helped improve access to timely mental health interventions.

PCN staff told us they really enjoyed working in the practice where they felt not only valued and heard but they could see patients were well looked after. Practice staff told us there was good teamwork a family feel to the practice and everyone was easily accessible. They were proud to work for the practice and some expressed their wish to be registered with the practice.

The GP partners described having a stable and longstanding partnership supported by an experienced and long-serving workforce. Staff adapted well to new technology and developments in modern general practice. The practice worked effectively with the University of Hertfordshire and the service provided at the university site was tailored to meet the needs of the student population. Leaders told us the relationship with the university was strong and collaborative, describing it as excellent.

The healthcare assistant (HCA) team undertook a range of clinical responsibilities including health checks, smoking cessation support, ECGs, pre-diabetes checks and hypertension reviews. The practice also operated as a training site for GP registrars, who were actively involved in the life of the practice and regularly presented topics, case studies and audits at weekly clinical meetings. Staff communication was supported through multiple channels, including an internal newsletter called “Potts Progress” issued as required, email communication during working hours, internal messaging via electronic notifications, in-house protected meetings and notices displayed in staff areas.

The practice provided care for approximately 112 residents at the local care home, with dedicated clinicians responsible for coordinating their care. We sought feedback from the care home who reported that residents with medical needs, including long-term conditions received regular reviews and support from the practice. Care home staff told us the lead GP maintained regular contact with the service and was available to discuss residents’ care needs when required. They also told us the service received GP visits twice a week as part of the enhanced healthcare support.

Care home staff told us they had a positive and well-established working relationship with the practice. They described the service as responsive, professional and supportive, with approachable staff and effective communication, including the monthly multidisciplinary team meetings chaired by the practice lead GP for the care home.

The practice also held monthly Gold Standards Framework (GSF) meetings, chaired by a GP, where patients on the palliative care register and those nearing end of life were discussed. These meetings involved multidisciplinary input, including a clinical nurse specialist from the hospice and members of community teams such as community nurses and respiratory nurses. Frail and housebound patients were also discussed, with opportunities for the frailty nurse to raise concerns and contribute to care planning.

The practice supported people to manage their health and wellbeing to maximise their independence, choice and control. They supported people to live healthier lives and where possible, reduce their future needs for care and support.

The practice was the first in Hertfordshire to achieve active practice status, reflecting its commitment to promoting physical activity among staff and patients. These included promoting movement among staff through awareness, desk-based exercises, standing desks and encouraging patients through educational materials displayed in waiting areas. The practice also organised staff activity challenges and supported patients to increase activity through initiatives such as a GP exercise referral scheme, structured programmes and local health walks. They worked in partnership with local organisations to support community-wide physical activity.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The practice participated in Primary Care Network (PCN) movement challenge competitions which were held periodically to support healthier lifestyles and engagement in physical activity. For example, the practice was celebrating the 10-year anniversary of their health walks which comprised 2 different walks for their mobile and less mobile practice population.

They also employed social prescribers who supported patients requiring additional non-clinical assistance. They were involved in running the Healthy eating hub and their health and wellbeing coach was involved in the Shape Up initiative, for which they received a community award.

Patients also had access to the practice smoking cessation advisor and NHS Health checks were offered to patients aged 40 to 74 years. Their practice Patient Participation Group (PPG) provided longstanding support, mainly assisting with the organisation and delivery of seasonal flu clinics. They had organised a series of “Health Matters” evenings, where patients were invited to attend sessions with guest speakers covering a range of health topics, including cancer, diabetes, Parkinson’s disease, dementia and hormone replacement therapy (HRT). One recent event attracted over 200 attendees and 2 GPs from the practice were involved in delivering the sessions. These initiatives supported patient engagement, education and self-management of health conditions.

The practice told us that their PCN won the ‘High Sherriff’s community champion award’ for all the initiatives they had created for patients and staff.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff were all involved in managing and monitoring long term conditions and patients with learning disabilities.They received a Purple Star accreditation for their patients with learning disabilities and we saw evidence of support provided to 1 of these patients in relation to medicines administration, which demonstrated a personalised approach to care.

The practice met national targets for childhood immunisations in 3 of the 5 indicators, with the lowest indicator for children aged 2 years old who had received their measles, mumps and rubella (MMR) immunisations at 88%, just below the 90% target.The practice told us there were a significant number of parents who were hesitant about vaccinations. They offered discussions with nursing staff to address concerns.

Cancer prevention data for 2024 showed the practice had not met national cancer screening targets. For example, cervical screening uptake in the last 3.5 years for women aged 25 to 49 years was 53%, below the 80% target. For women aged 50 to 64 years, uptake for the last 5.5 years was 79%, slightly below the 80% target. The practice identified that cervical screening uptake was lower among some groups of patients; for example, university students from overseas who were less familiar with local services. Staff told us that this lack of familiarity contributed to some student patients declining screening.

The practice also told us there had been a significant shift in the demographics of their patient population over time, with an increase in international students, particularly from India and Nigeria. This impacted the interpretation of some population health data. For example, lower uptake of cervical screening was partly attributed to some students declining screening for cultural reasons or not being sexually active, which may affect performance against national indicators. However, they should continue to monitor and encourage screening for this population group.

The practice continued to take steps to increase uptake of cervical screening. Nursing staff monitored patients due for screening and proactively contacted them to raise awareness and support access to appointments. The provider also operated a recall system and contacted patients to encourage attendance. Patients who declined screening were asked to complete a disclaimer and those who did not respond to 3 invitations were coded as exceptions in line with national guidance, which supported performance against screening targets.

The practice offered sexual health screening services, including provision at the university site to improve access for this patient group. Immunisations including meningitis ACWY, were also offered in line with national guidance.

The practice carried out quality improvement activity across the practice population groups such as prescribing audits, asthma audits and an ADHD audit. From the clinical notes we reviewed, we found that most people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance. Clinicians were invited to present their audit findings at their monthly meetings.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. Not all staff, however, had had recent training in the mental capacity act or consent.

The practice had policies and procedures for obtaining consent to care and treatment, aligned with current legislation and guidance and a designated lead was in place. The consent and Mental Capacity Act (MCA) policy was implemented in September 2025. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. We also saw best interest decisions used for a patient in the care home with no capacity to make decisions and with no next of kin.

Staff understood and applied legislation relating to consent and described the consent process with regards to immunisations. Capacity and consent were recorded in patient records. However, while most staff were up to date, training had expired for 5 staff in relation to the Mental Capacity Act and a further 5 staff in relation to consent training. Training gaps meant the provider could not be assured all staff had up-to-date knowledge of consent and MCA requirements, creating a risk that these may not be applied consistently.