Potterells Medical Centre

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• 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

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

This service scored 68 (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 had a shared vision, strategy and culture. Although we were not provided with a copy of their statement of purpose, the practice submitted their mission statement which outlined their shared vision and culture which was based on transparency, equity, equality and human rights, as well as diversity and inclusion and engagement. Together with the University of Hertfordshire medical centre, they were committed to delivering exceptional primary care services to the communities around North Mymms, as well as the students at the University of Hertfordshire.

Their mission was to make a commitment to deliver safe, effective, patient-centred care, with timely access to skilled and compassionate professionals. They supported continuous staff development to enhance care quality and aimed to be trusted partners in improving community health and wellbeing.

The practice was aware of the projected increase in the local population and was working with partner agencies to address future challenges. They fullyunderstood the challenges and the needs of people and their communities. For example, they recently switched to a total triage model known as Modern Access in February 2026 following extensive preparation and planning. This aimed to improve continuity of care and meet the needs of a predominantly digital‑first student population, while enabling flexible rota management and a balance between same-day and future appointments. The system remained under ongoing review and refinement; however, the approach had been largely successful, with evidence of highly positive feedback from patients, although some required time to adapt.

Despite this, the practice was also aware of the challenges and raised concerns that the requirement to provide unlimited online access for non-urgent requests during core hours could adversely affect waiting times. They anticipated a significant increase in demand, which may require the introduction of waiting lists. There were concerns this could contribute to workforce pressures, including burnout and reduced workforce capacity, within the context of a growing and ageing population. The practice indicated that this approach may require further and ongoing consideration by national policymakers and GP representative bodies.

The practice recognised future challenges, including increased demand from planned housing developments locally with green belt developments on the horizon of 400 new homes and the limitations of the current premises which were last refurbished in 2004 and which they felt were no longer fit for purpose. Engagement was ongoing with the integrated care board and Patient Participation Group (PPG). This was consistent with our observations on assessment, with 2 portacabins being used onsite. Staff felt the planned building changes were recognised as likely to impact staff.

There were also recognised risks relating to workforce succession, and the practice had begun initial discussions about developing a succession plan to enable the practice to retain stability and its current ethos. A strategy meeting was held in July 2025 comprising GP partners, members of the PPG and management, to brainstorm a strategy of the future of the practice. Leaders advised that these plans required further development as they were not yet clearly defined.

Most of the staff also told us they contributed to the strategy of the practice; for example, staff described opportunities to contribute to the practice vision through meetings and discussions. Clinical staff and partners reported involvement in reviewing the mission statement and providing feedback, including discussions on individual and collective future plans. Some staff, including nursing staff, confirmed ongoing involvement in planning. However, not all staff were engaged. Some non-clinical and administrative staff reported limited, or no awareness of the strategy or mission statement and one staff member noted they had not been involved as this work took place prior to their employment. The practice should ensure that all staff are consistently involved in the development and understanding of the strategy to promote a shared vision and inclusive culture.

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.

Staff told us leaders in the practice were approachable, responded to any concerns raised and modelled the values of the practice. We saw the leadership team worked with other practices in the primary care network (PCN) and were engaged in the development of primary care services within the local area.

The practice described a positive team culture characterised by approachability, strong working relationships, and a flat hierarchy. Staff reported working well together, supported by regular formal and informal meetings. Despite increasing resource pressures, the practice maintained good access and aimed to provide proactive care, including long-term condition and frailty reviews. They aimed to deliver high-quality patient care, with a strong focus on community engagement and staff wellbeing, which was consistent with our findings on assessment.

Staff retention was high, with several partners having worked at the practice for over 20 years, indicating stability and continuity of leadership. The practice was also seen to work well with partners and stakeholders, supporting access to a wide range of services and had been recipients of several awards in the past. These included the Active Practice Charter, being the first practice in Hertfordshire to achieve such a status. They were also involved in running the Healthy eating hub and their health and wellbeing coach was involved in the Shape Up initiative. They had received a community award for this. Their PCN also won the ‘High Sherriff’s community champion award’ for all the initiatives they had created for patients and staff.

Feedback from members of the Patient Participation Group (PPG) described improvements in practice leadership and service delivery over time. Earlier challenges included increasing demand, IT limitations and staffing pressures. Following changes in leadership, including the appointment of a new practice manager, patients reported strengthened administrative systems and the improved use of IT.

Patient feedback described a consistently positive experience over a long period, with no reported need to raise complaints. The practice was regarded highly locally, with patients highlighting efficient systems, a culture of continuous improvement and consistently high-quality, responsive care from all staff.

Patients reported that clinicians listened, provided clear explanations and made timely referrals where needed. Continuity of care was supported by long-standing staff, including partners, care navigators and nurses. Online services were described as effective, enabling prompt management of prescriptions, appointments and access to medical information.

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, although some complaints were reported.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The practice leadership welcomed a culture that promoted openness, honesty and approachability.

There was a whistleblowing policy, Freedom to Speak up policy as well as a bullying and harassment policy in place. Staff were encouraged to raise concerns and speak up about any wrongdoing, with this being positively recognised. All staff, except for 1, had completed and were up to date with the mandatory bullying and harassment training.

We carried out staff interviews as part of the remote and onsite assessments. Partners were described as supportive of the practice managers who were able to speak up, although this could be challenging given their role as their employers. Staff described leaders as mostly approachable and responsive, providing examples where changes were implemented following their suggestions; for example, rota changes had been discussed and actioned and staff reported feeling listened to. However, we did receive feedback from 1 staff member who reflected differences in approachability across the management team. We noted that communication between some members of the management team could be improved.

Prior to the assessment, CQC sent all staff working at the practice individual staff feedback forms. The practice had a diverse workforce, so these feedback forms were confidential and voluntary, whilst offering the practice staff an opportunity to feedback their experiences of working at the practice, as well as to hear their individual voices in a way we would not normally have previously done on assessment due to time constraints. Of the 41 forms sent, we received 19 responses where staff gave us greater insight into their individual roles, including their understanding of the policies and procedures at the practice. Feedback from staff showed they were aware of how to raise concerns and mostly felt confident in doing so.

The practice had established Freedom to Speak up arrangements within their primary care network (PCN) and this information was included in their Freedom to Speak up policy, so staff were aware of how to raise concerns to the guardian.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for staff.

Policies and procedures to promote diversity and equality were in place and staff had received training, except for 2 staff members who did not have these training records on file.

We saw that senior leaders had arrangements in place to address concerns related to discrimination. However, further action was required to ensure staff had access to occupational health services, as the infection prevention and control audit carried out in February 2023 showed that staff did not have access to occupational health. There were also no clear arrangements in place to support staff working in the practice who may be covered under the Equality Act, such as those with disabilities but who held additional lead responsibilities.

Adjustments had been made to support staff wellbeing, demonstrating that staff were valued. For example, we saw support in place for unwell staff members, which aligned with feedback from several staff who reported feeling supported during periods of illness. We also saw reasonable adjustments in place for a staff member with a health condition, demonstrating consideration for individual wellbeing.

We did not see a conflict-of-interest policy in place to identify and manage potential conflicts, such as family relationships in the practice, to ensure fairness and equality. In a GP setting, where close working relationships and decision-making responsibilities overlap, the practice should consider clear and robust policies that are essential to maintain transparency, mitigate bias and ensure that all staff and patients are treated equitably.

The practice advised that staff were able to register as patients, with approximately 5% of staff registered at the practice; however, we did not see that there were appropriate policies and procedures in place to manage this arrangement.

We also found that partners’ meeting minutes were recorded using handwritten notes. This approach to documentation did not fully support effective oversight, as it may limit the consistency, accessibility and auditability of records. The absence of clearly documented, shared and trackable minutes could reduce assurance that decisions, actions and associated risks were formally captured, monitored and followed up in a timely manner.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to complete appraisals and performance reviews. The provider had established governance processes that were appropriate for their service. Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

There were governance systems in place, including clear roles, responsibilities and regular leadership oversight through weekly partner, management and senior nurse meetings. Staff had access to policies and procedures, and a comprehensive business continuity plan was in place and understood by staff.

However, we identified several gaps in governance arrangements, including recruitment, appraisals, significant event management, complaints handling, training compliance and the sharing of learning.

Monitoring of mandatory training was not effective, with gaps across several areas despite leaders being aware. Some policies had not been reviewed in line with required timescales, with gaps of up to three years, and the annual health and safety return for the university site was incomplete and outdated, increasing risks.

Systems for learning and continuous improvement were not sufficiently robust, with inconsistencies in staff understanding of patient safety alerts, complaints and governance processes, including staff immunisations. Record-keeping and documentation were not consistently maintained, including incomplete audit records and handwritten meeting notes. Communication systems also required improvement, as meeting minutes were not consistently shared and staff reported reliance on informal communication. Improvements were needed in risk assessments and the completion and follow-up of action plans, particularly at the university site.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people and could be improved.

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 practice was in a rural area with a planned housing development of 400 houses expected to increase demand and exacerbate existing space constraints. The practice worked in partnership with the integrated care board to provide interim solutions. As an interim measure, the integrated care board funded a 2-room portacabin from December 2023 to December 2028; however, this was not an optimal solution, with reported issues including leaks and excessive heat in the summer. The integrated care board’s premises team was engaged with the practice regarding future plans. Due to current constraints and anticipated population growth, the practice was ranked 10th out of 200 premises in terms of need within the integrated care board.

The practice worked in partnership with their Primary Care Network (PCN), the local council and community to deliver Hatfield Health Day in summer 2025, organised by the PCN and Hatfield Council. Approximately 600 patients attended. The event included sports and activity demonstrations, as well as educational sessions such as mindfulness, with a focus on promoting healthy ageing.

The practice also worked with other practices within their PCN to offer extended access and vaccination programmes. Staff had improved coordination of their service with community healthcare services.

They also had an active and engaged Patient Participation Group (PPG) of 18 long-standing members, who also assisted the practice with their flu clinics. The practice told us they had insightful discussions with the Patient Participation Group (PPG), who shared both their own perspectives and feedback gathered from the wider community, helping the practice to understand and respond to the evolving needs of the local population. They also reiterated that they established a village walking group and in addition, the practice received recognition for its contribution to community health and fitness, receiving an award from the High Sheriff of Hertfordshire.

PPG feedback indicated clear improvements following their involvement. Members reported regular attendance from practice representatives at meetings and active engagement in service developments, including the introduction of a new phone system and website improvements. They described significant involvement in implementing total triage, which they reported as a success, and collaborative working across the Primary Care Network (PCN), including shared learning with other practices. They also contributed to a series of community health events (“Health Matters”), covering topics such as dementia, diabetes, cancer, mental health, COPD, and Parkinson’s disease, with attendance of around 60 people per session.

The PPG also demonstrated proactive and innovative engagement with the practice and wider community, including supporting menopause education events, although not all 200 registered attendees were able to attend. They also described a strong and effective working relationship with the practice, highlighting joint involvement in community events. For example, a recent large-scale event, which included multiple health promotion stalls, attracted several hundred attendees and focused on areas such as falls prevention, demonstrating collaborative efforts to improve patient experience and wellbeing.

They also told us they felt the practice responded effectively to the COVID-19 pandemic and expanded capacity through additional consulting space. As a PPG, they were actively engaged in supporting non-clinical developments, including digital improvements and planning processes.

Feedback from wider healthcare providers was consistently positive, indicating a good local reputation. The practice reported strong performance in the 9 care processes and diabetic control indicators. They told us the lead GP was contacted by the integrated care board and invited to share good practice with other providers, reflecting recognition of the practice’s performance.

Since 2005, Potterells Medical Centre has been accredited as a Training Practice of medical students and GP registrars. Experienced trainers had contributed to the development of approximately 60 GPs, many of whom were working locally. This included former trainees now in leadership roles, demonstrating sustained impact on the local workforce. The GP registrars had typically completed 2 to 4 years of hospital-based training across a range of specialties and conducted consultations independently, with appropriate supervision and support from a designated trainer. At the time of assessment, the practice had 2 GP registrars in post.

The service focused on continuous 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.

The practice had a quality improvement plan in place to help drive improvements in services. This focused on the appointment system. All staff were encouraged to put forward and test out new ways of working, and we saw examples of this.

Audits, clinical improvement and policy reviews were discussed at monthly meetings held every third Monday, where clinicians were encouraged to present topics. In addition, quarterly cancer care review meetings were held, typically on the fourth Monday of the relevant month. These meetings reviewed new cancer diagnoses, the pathways to diagnosis, and identified any learning from cases or events.