BPAS - Streatham...4 BPAS - Streatham Quality Report 29/01/2020 BPAS Streatham Services we looked at...

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this location Requires improvement –––

Are services safe? Requires improvement –––

Are services effective? Requires improvement –––

Are services caring? Good –––

Are services responsive? Requires improvement –––

Are services well-led? Inadequate –––

Overall summary

BPAS Streatham is operated by British PregnancyAdvisory Service. BPAS Streatham provides medical andsurgical termination of pregnancy services, feticidetreatment, screening for sexually transmitted diseases,contraception advice, counselling and vasectomyprocedures. The service provides surgical terminationsup to 23 weeks plus six days gestation and medicalabortions up to nine weeks plus six days gestation.Facilities include one treatment room, five consultingrooms a two stage recovery area, and a discharge area.

There was an early medical unit based within a healthcentre in Southwark. Early medical abortion treatmentand consultations in the early stages of pregnancy wereoffered in a private room at this facility.

The service provides termination of pregnancy, sexualhealth screening and family planning services. Weinspected this service using our comprehensiveinspection methodology. We carried out theunannounced part of the inspection on 5,6,16,18September 2019.

BPBPASAS -- StrStreeathamathamQuality Report

Leigham Clinic76 Leigham Court RoadLondonSW16 2QATel:03457304030Website:www.bpas.org

Date of inspection visit: 5,6,16,18 September 2019Date of publication: 29/01/2020

1 BPAS - Streatham Quality Report 29/01/2020

To get to the heart of patients’ experiences of care andtreatment, we ask the same five questions of all services:are they safe, effective, caring, responsive to people'sneeds, and well-led? Where we have a legal duty to do sowe rate services’ performance against each key questionas outstanding, good, requires improvement orinadequate.

Throughout the inspection, we took account of whatpeople told us and how the provider understood andcomplied with the Mental Capacity Act 2005.

The main service provided by this hospital wastermination of pregnancy services.

Services we rate

We rated it as Requires improvement overall.

We found areas of practice that require improvement:

• There was a corporate governance structure in place,however this was not effective at local level. Localgovernance arrangements did not ensure theidentification, mitigation and monitoring of risks orthe improvement of quality. There was a fractiousrelationship between some leaders and staff, andstaff did not always feel valued or supported. Wewere not assured information fed into the monthlydashboard was accurate.

• The monitoring of staff mandatory training andcompetencies was not managed well. There was noformalised tracking until very recently, and this hadyet to be embedded into the service. Not all staff hadreceived an annual appraisal or regular performancereviews.

• There was not a strong culture for the reporting andsharing of feedback from incidents. We were notassured incidents of all levels were being reported.

• Waiting times from initial referral to treatment werenot in line with Royal College of Obstetricians and

Gynaecologists (RCoG) national guidance andRequired Standard Operating Procedures (RSOP) 11:Access to timely abortion services. Patients could notalways access the service when they wished. 54% ofsurgical termination of pregnancy patients above 14weeks gestation, waited more than 10 days.

• Not all equipment was in good working order or hadbeen calibrated.

However:

• Staff treated patients with compassion and kindness,respected their privacy and dignity, took account oftheir individual needs, and helped them understandtheir conditions. They provided emotional support topatients, families and carers.

• The service had suitable premises and all areas ofthe clinic were visibly clean and clutter free. Theclinic was wheelchair accessible with accessibletoilets and a lift to all floors.

• Staff completed patient records accurately andstored them safely.

• The service treated concerns and complaintsseriously and investigated them. The serviceincluded patients in the investigation of theircomplaint.

Following this inspection, we told the provider that itmust take some actions to comply with the regulationsand that it should make other improvements, eventhough a regulation had not been breached, to help theservice improve. We also issued the provider with onerequirement notice that affected BPAS Streatham. Detailsare at the end of the report.

Nigel Acheson

Deputy Chief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Terminationof pregnancy

Requires improvement –––

BPAS Streatham is operated by British PregnancyAdvisory Service (BPAS). It comprises one mainlocation in South London and one satellitein Southwark. The service provides termination ofpregnancy as a single speciality service. We ratedthis service requires improvement for safe,effective, responsive and well led and good forcaring. Overall the service was rated requiresimprovement.

Summary of findings


Contents

PageSummary of this inspectionBackground to BPAS - Streatham 6

Our inspection team 6

Information about BPAS - Streatham 6

The five questions we ask about services and what we found 8

Detailed findings from this inspectionOverview of ratings 11

Outstanding practice 34

Areas for improvement 34

Action we have told the provider to take 35

Summary of findings


BPAS Streatham

Services we looked atTermination of pregnancy

BPASStreatham



Background to BPAS - Streatham

BPAS Streatham is operated by British PregnancyAdvisory Service. The British Pregnancy Advisory Serviceis a British charity whose stated purpose is to supportreproductive choice by advocating and providing highquality, affordable services to prevent or end unwantedpregnancies with contraception or by termination ofpregnancy. The service is registered as a single specialtyservice for termination of pregnancy and is registered forthe following activities:

• Diagnostic and screening procedures

• Family Planning

• Surgical Procedures

• Termination of Pregnancy

• Treatment of disease, disorder or injury.

Services provided at the early medical unit included:

• Pregnancy testing

• Unplanned Pregnancy Counselling/Consultation

• Medical Abortion

• Abortion Aftercare

• Miscarriage Management

• Sexually Transmitted Infection Testing

• Contraceptive Advice and Treatment

The service has had a registered manager in post sinceOctober 2018

Our inspection team

The team that inspected the service comprised a CQClead inspector, two other CQC inspectors, and assistantinspector. The inspection was overseen by CarolynJenkinson, Head of Hospital Inspection.

Information about BPAS - Streatham

BPAS Streatham is open five days a week, Sunday toThursday from 7.30am to 6pm. The Southwark earlymedical unit satellite clinic was available from Thursdayand Friday from 9am to 4pm. The satellite clinic is locatedin a suite of consulting rooms, within a GP practice, whichare leased by BPAS on a sessional basis.

BPAS Streatham has been opened for several decadesand provides services for women of reproductive age andmen from all areas of the UK, and sometimes overseas,although the majority of patients come from withinLondon based clinical commissioning groups (CCG).

The clinic offers consultation, medical assessment,counselling and treatment. As part of the care pathway,patients are offered sexual health screening andcontraception. Patients are able to choose the treatmentthat they have, based on their gestation, which includes,

early medical abortion up to nine weeks and six daysgestation, and surgical termination up to 23 weeks andsix days gestation. Surgical termination of pregnancy(SToP), between seven and 14 weeks gestation, wasoffered using local anaesthesia, conscious sedation andno anaesthetic according to patients wishes. Surgicalabortions up to a gestation 23 weeks and six days wereoffered under general anaesthetic. Medical feticide isprovided before late gestation surgical abortions. Feticideis induced demise of the foetus.

During the inspection, we visited BPAS Streatham andBPAS Southwark satellite unit, we spoke with 16members of staff including registered nurses andmidwives, client care coordinators, and senior managers.We spoke with seven patients and reviewed 10 sets ofpatient records.

Summaryofthisinspection

Summary of this inspection


There were no special reviews or investigations of thehospital ongoing by the CQC at any time during the 12months before this inspection.

Activity (April 2018 to March 2019)

• There were 5151 episodes of care recorded at theearly medical unit (EMU) and BPAS Streatham.

• 2322 were medical terminations of pregnancy

• 2388 were surgical terminations of pregnancy

• 441 were surgical terminations of pregnancy after 24weeks

Track record on safety

• There were no never events recorded for the periodApril 2018 to March 2019.

• There were two serious incidents recorded for theperiod April 2018 to March 2019.

From April 2018 to March 2019 the service received 15formal complaints. All complaints received wereresponded to within 20 days which was in line with theprovider’s complaints policy.

Services provided at the location under service levelagreement:

• Clinical and non-clinical waste removal• Interpreting services

• Maintenance of equipment

Certain mandatory training modules




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?Are services safe?

We rated it as Requires improvement because:

• Not all staff had completed mandatory training core modules,and systems to track and monitor training were not fullyembedded into the service.

• At the time of our inspection there was a lack of effectivemonitoring to ensure staff had received the appropriatesafeguarding training.

• At the time of inspection not all equipment was in goodworking order or regularly calibrated. The scanner in thetreatment room and the backup generator were both awaitingreplacement, with orders placed but not yet received.

• Security to the treatment room was not sufficient. None of thedoors which had locks were secure and we could easily gainaccess with no restrictions throughout our inspection.

• There was no formalised medicine management training orrefresher training as stipulated in the medicine managementpolicy, and this had been highlighted on the risk register.However the organisation was in the process of organising this.

• The service did not always manage patient safety incidentswell. Staff did not always report incidents and lessons learntwere not always shared with the whole team.

However:

• The service controlled infection risk well. Staff used equipmentand control measures to protect patients, themselves andothers from infection. They kept equipment and the premisesvisibly clean.

• Staff completed and updated risk assessments for each patient.Staff identified and quickly acted upon patients at risk ofdeterioration.

• Staff kept detailed records of patients’ care and treatment.Records were clear, up-to-date, stored securely and easilyavailable to staff providing care.


Are services effective?Are services effective?






• The service did not always make sure staff remained competentand up to date with their roles. We found one staff recordidentified competencies had not been signed off since they hadstarted their employment over three years ago.

• There was a lack of effective processes to ensure agency staffhad basic competencies to perform their role within the service.Recently the clinic had identified that agency staff had notreceived immediate life support (ILS) training and were onlytrained in level 2 safeguarding.

• Staff appraisals and supervision meetings were sporadic andinconsistent.

However:

• The service provided care and treatment based on nationalguidance and evidence-based practice.

• Staff worked together as a team to benefit patients. Theysupported each other to provide care and communicatedeffectively with other agencies.

• Staff supported patients to make informed decisions abouttheir care and treatment. They knew how to support patientswho lacked capacity to make their own decisions or wereexperiencing mental ill health.

Are services caring?Are services caring?

We rated it as Good because:

• Staff treated patients with compassion and kindness, respectedtheir dignity, and took account of their individual needs.

• Staff provided emotional support to patients, families andcarers to minimise their distress. They understood patients’personal, cultural and religious needs.

• Staff supported and involved patients, families and carers tounderstand their condition and make decisions about theircare and treatment.

• Patients could access ongoing support should they need it.

Good –––

Are services responsive?Are services responsive?


• People could not always access the service when they neededit. Waiting times for surgical treatments, did not meet RCoGnational guidelines. This meant patients did not always receivecare and treatment within the given timeframes set out byRSOP 11: Access to timely abortion.





• The centre had experienced problems with the externaltranslation company they used.

• The clinic had recently started to offer to patients the home useof misoprostol. However, we found women were not offered thechoice of returning to the clinic to take the second tablet if theywanted to.

However:

• The service was inclusive and took account of patients’individual needs and preferences. Staff made reasonableadjustments to help patients access services. They coordinatedcare with other services and providers.

• The service treated concerns and complaints seriously,investigated them and shared lessons learned with all staff. Theservice included patients in the investigation of their complaint.

Are services well-led?Are services well-led?

We rated it as Inadequate because:

• Local leaders did not always have the skills and abilities to runthe service. They did not always understand and manage thepriorities and issues the service faced. They did not alwayssupport staff to develop their skills and expertise.

• Staff did not always feel respected, supported and valued.• Some local leaders did not always operate effective governance

processes, throughout the service. Staff did not always haveopportunities to meet, discuss and learn from the performanceof the service.

• Risks were not always fully identified, and actions taken toreduce their impact.

• Not all staff understood the vision or strategy of the service.

However:

• Leaders and staff actively and openly engaged with patients,the public and local organisations to plan and manage services.

• There was evidence that some leaders and teams used systemsto manage performance effectively.

Inadequate –––




Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Termination ofpregnancy

Requiresimprovement

Requiresimprovement Good Requires

improvement Inadequate Requiresimprovement

Overall Requiresimprovement

Requiresimprovement Good Requires

improvement Inadequate Requiresimprovement

Detailed findings from this inspection


Safe Requires improvement –––

Effective Requires improvement –––

Caring Good –––

Responsive Requires improvement –––

Well-led Inadequate –––

Are termination of pregnancy servicessafe?


We rated Safe as requires improvement.

Mandatory training

The service provided mandatory training in key skillsto staff, however we were not assured they made sureeveryone completed it.

• Staff completed mandatory training through e-learningmodules and face to face training. Topics covered formandatory training included, safeguarding level 3,health and safety, infection control, informationgovernance, basic life support, immediate life support,fire awareness moving and handling and medical gases.

• There had been a lack of effective monitoring,management and oversight of mandatory training at alocal level. This had been recognised and a new trainingrecord was in the process of being implemented at thetime of inspection. The new system used a red, amber,green (RAG) rating to identify staff compliant (green),training booked (amber) and training overdue (red). Thiswas yet to be fully embedded.

• Inconsistencies in evidencing staff training had occurredfollowing a change to the central training system atBPAS head office. At the time of this inspection, thetemporary treatment unit manager (TUM) was manuallychecking individual staff files to cross reference andupdate the new training record.

• We found one staff member had no evidence they hadcompleted immediate life support training, since theyhad started at the centre. This staff member has sincebeen booked on a course.

• Post inspection information at the end of September2019 showed of the 12 mandatory training modules, twohad a 100% completion rate. 60% of staff hadcompleted basic life support training and 89% of staffhad completed ILS training. We saw courses had beenbooked in October for staff to complete the training. Itwas estimated that all staff would have completed theirmandatory training by the end of December 2019.

• At the time of our inspection there were no files updatedor recorded centrally, to identify if staff had receivedsepsis training. Out of 24 members of staff, only ninestaff had received sepsis training, which equated to 37%of staff. Staff members were booked for online trainingbut, there was no ‘sweep up’ process for track andtracing. This was added to the risk register on 10September 2019.

Safeguarding

Staff understood how to protect patients from abuseand the service worked well with other agencies to doso. Not all staff had training on how to recognise andreport abuse.

• At the time of our inspection the monitoring that was inplace in relation to safeguarding training compliancewas not fully effective. We found two staff members hadnot completed safeguarding level 3 training, one staffmember for over three years. The current mandatory

Terminationofpregnancy

Termination of pregnancy



training safeguarding level 3 training was 64%. Whilststaff sickness had impacted full compliance, there was alack of proactive oversight to address this in a timelymanner.

• Those staff who had received training for Safeguardinglevel 3 knew how to recognise and report abuse and hadreceived specific training in relation to child sexualexploitation (CSE), gang culture, domestic abuse afemale genital mutilation (FGM).

• There was an up to date and accessible safeguardingpolicy which supported staff and gave clear guidelineson roles and responsibilities for reporting and escalatingsafeguarding. Staff we spoke with were clear on theirroles and responsibilities for reporting and escalatingsafeguarding concerns.

• The registered manager was the designated member ofstaff responsible for acting upon adult and childsafeguarding concerns locally and co-ordinated actionwithin the clinic, escalating to the lead nurse forsafeguarding at provider level. Staff were able to contactthe lead nurse for safeguarding when the registeredmanager was not at the centre.

• The domestic abuse policy included information forstaff to recognise and report on FGM. A risk assessmentwas completed, and concerns escalated to the policeand social services. The clinic had identified three FGMcases from December 2018 to March 2019 and these hadbeen escalated through the correct channels.

• Staff completed a risk assessment for all patients underthe age of 18 years. The confidentiality of patients waskey. Receptionists did not announce full names atreception and the information technological (IT) systemflagged up those patients under the age of 18 years andany previous safeguarding referrals.

• Patient care co-ordinators saw all patients on their ownfor the initial consultation and the client care managerwho had received counselling training could be calledupon if concerns were identified. The client caremanager oversaw all safeguarding for patients under 18years of age.

• Staff we spoke with during the inspection were able todescribe safeguarding incidents they had escalated andreported, and staff had a good understanding of how toidentify safeguarding incidents.

• The service met the psychological needs of children andadults by offering both pre and post abortioncounselling services. Observations of consultations andreviewing patient records showed staff offered theseoptions for all patients. The ‘My BPAS Guide’, given to allpatients who received treatment, contained informationon how to access counselling services.

• There were posters and leaflets displayed throughoutthe clinic regarding different types of abuse such asdomestic abuse and sexual exploitation. These providedadvice and support service telephone lines and patientswere able to take these leaflets home with them.

• Patients under the age of 13 were not treated at theclinic. There were clear guidelines for staff to follow andescalate and staff were able to tell us the actions theywould take, for patients under 13 years. This includedescalating to the safeguarding lead and contacting thelocal authorities safeguarding service, the police andreferring the child to the NHS.

Cleanliness, infection control and hygiene

The service-controlled infection risk well. Staff usedequipment and control measures to protect patients,themselves and others from infection. They keptequipment and the premises visibly clean.

• Staff used control measures to prevent the spread ofinfection. There were in date and ratified policies andprocedures to guide staff and staff completed infectionprevention and control (IPC) mandatory training.Information received after our inspection showed 92%of staff had completed IPC training, which includedseven members of staff who had completed the trainingduring and after our inspection dates.

• Staff wore personal protective equipment (PPE) whentreating patients and this included clean disposablegloves, uniform, aprons and masks dependant on thepatient’s treatment. There was a good selection andavailability of PPE stock throughout the clinic.

• Staff washed their hands in accordance with the WorldHealth Organisation (WHO) ‘Five moments for handhygiene’ and ‘bare below elbows’ guidance. Weobserved staff following good hand hygiene practicesthroughout the inspection which included the use ofhand gel.





• There was an IPC link practitioner who had receivedenhanced IPC training and they had an afternoon perweek to complete IPC tasks such as audits.

• Monthly audits of infection control measures wereundertaken using BPAS Infection Control Essential StepsAudit Tool. The tool looked at four areas, hand hygiene,use of PPE, aseptic technique and use and disposal ofsharps. The set organisational target was 100%. Auditswe viewed from February 2019 to July 2019 showed theclinic consistently scored 100% for hand hygiene, PPEand aseptic techniques.

• An infection prevention environmental audit wasundertaken by the area nurse in July 2019. The auditincluded IPC checks in areas such as waste disposal,general environment, linen and care of equipment. Theresults were colour coded and the clinic scored greenwhich meant the score was above 90%. The auditshowed areas of concern, for example, non-compliancewith sharps disposal management. Actions takenincluded an email sent to staff to reinforce the correctsharps disposal methods. During the inspection wefound staff were correctly following sharps disposal.

• The risk register had a risk related to the daily checklistsused for IPC. It was highlighted by the new TUM that thelists used were not in-depth enough and were notfollowing BPAS infection control policy. At the time ofour inspection, the checklists had been updated,circulated and included more detailed checks for staff toundertake.

• A deep clean of the treatment room occurred on athree-monthly basis. A house keeping service was inoperation five days a week in the mornings andafternoons. We saw cleaning schedules werecompleted, dated and signed for the areas that hadbeen cleaned.

• During the inspection we found staff disposed of clinicalwaste correctly. Clinical waste was locked in securecontainers until collected by a specialist external wastecompany.

• Medical equipment and consumables were a mixture ofsingle use and reusable items. Reusable items were sentto an external company for decontamination andsterilisation.We saw traceability stickers were placed inpatient records, to identify pieces of equipment usedduring their treatment.

Environment and equipment

The service had suitable premises and equipment andlooked after them well. However, doors leading to thetreatment room were unlocked and not all equipmenthad been calibrated.

• The design, maintenance and use of the premises andequipment were suitable for purpose. The organisationwas in the process of planning to make adjustments tothe building to improve the quality of services forpatients. For example, updating the air conditioning unitand reassessing the layout of the building to ensurethere was a better patient flow through the centre.

• All maintenance certificates were kept up to date locallyand were logged onto a central electronic file. We sawthat all equipment within the service had been servicedwithin agreed timescales. Maintenance contracts weremanaged by head office.

• We were told there had been recent problems with thebackup generator. During the weekly test the generatorsometimes did not start on the first turn and the servicehad had to call an engineer. We were told that so far, thishad not impacted on the service and there had been noincidents reported due to the generator not working. Wesaw an e-mail to show the organisation had agreed thepurchase of a new machine but did not see when thiswould be implemented.

• We checked 10 consumables items and found thesewere in date. Equipment we checked had been servicedand had stickers to indicate the item had passed theservicing checks. However, at the time of our inspectionwe found oximeters (a test used to measure the oxygenlevel of the blood) had no information to indicate if theyhad been electrically tested. The risk register identifiedthat the calibration of blood pressure machines andweighing scales was not effective and that better checksand records of calibration were required. Actions takenshowed new equipment had been purchased andcalibrated but the 5kg weighing scales still neededreplacing. This meant there was no way of knowing ifthey are working correctly and the potential risk beingpatients could be misdiagnosed. At the time of ourinspection this was still an ongoing issue.

• Staff had reported that the scanner in the treatmentroom was not working properly. The image wassometimes distorted and at times switched off on its





own accord. This had been recently placed on the riskregister, and the service had arranged for the scanner tobe replaced and was due at the end of September 2019.The risk register stated that the machine was safe to usein the interim period but was not desirable. We weretold no patient incidents had occurred or been reporteddue to the unreliable scanner. We were told there wasanother scanner that could potentially be used withinthe centre, but this had not been required.

• Lifesaving equipment such as a resuscitation trolley anda defibrillator were available, and staff completedchecks to ensure the equipment was in good workingorder. We saw these checks had been made.

• We saw suitable arrangements for the disposal ofclinical waste. Waste was segregated into appropriatebins with different colour coding. The disposal andstorage of hazardous waste was in line with nationalstandards and clinical waste was collected by anexternal specialist waste company. Waste disposal waschecked as part of the monthly infection preventioncontrol audit. The audit of February 2019 showed staffwere compliant when following the correct proceduresfor the disposal of waste.

• Security cameras were in place at the front of thebuilding and surrounding environment and visitorsgained entry by using an intercom and buzzer system.

• During our inspection we found security to thetreatment room was not sufficient. We could easily gainaccess with no restrictions, throughout our inspection.

• There was a major haemorrhage kit kept in thetreatment room and we saw this had been regularlychecked and signed to confirm the kit was ready for use.

• Medical gases were all in date and stored correctly.

Assessing and responding to patient risk

Staff completed and updated risk assessments foreach patient. Staff identified and quickly acted uponpatients at risk of deterioration.

• Staff completed full risk assessments prior to treatmentduring the pre-assessment stage. Further checkscontinued throughout the patient’s treatment journey.The assessments included a venous thromboembolism(VTE) assessment, a blood test to check for rhesusnegative blood and an ultrasound. Risk assessments

included a discussion on the reasons why the patientwas requesting a termination and the different optionsavailable to them, such as counselling services. Riskassessments had been completed in 10 records weviewed.

• Pre-operative assessments were completed before anysurgical treatment. Surgeons and anaesthetistsreviewed patients in order and to identify any risks. Asafety huddle took place every morning where eachpatient was discussed, and any risks were considered.The huddle clarified roles of responsibility for the dayand the huddle was well attended by all staffparticipating in treatments for that day.

• Patients eligibility for abortion assessments wereroutinely conducted. Patients who required furtherspecialist care were referred to the BPAS suitability teamfor medical review.

• There was a formal transfer agreement in place with anNHS hospital for deteriorating patients. This hadrecently been updated in July 2019. There was a total offive patients transferred within the last 12 months.Regular meetings were held with the NHS trust whereeach individual patient case was discussed, and lessonslearnt. A lead consultant from the NHS trust wascurrently working under a shared contract agreementbetween BPAS and the trust.

• Staff used a nationally recognised modified earlywarning score system (MEWS) tool to identifydeteriorating patients. Staff had a good knowledge ofescalation procedures and what to do in the event of adeteriorating patient. Staff described how they woulduse the MEWS tool and who they would escalateconcerns to. The surgeon stayed onsite until the lastpatient was declared fit for discharge. The organisationsperioperative care policy and procedure included theBPAS modified early warning system.

• The service had a policy for the management of thedeteriorating or septic client. This clearly outlined howstaff were to use MEWS and escalate to senior staffappropriately. Completion of MEWS was audited as partof the service’s general anaesthetic and bi-yearlyconscious sedation and local anaesthetic audits. Wesaw that for February 2019 the service achieved a 100%completion rate for MEWS.





• The service used the World Health Organisation (WHO)and five steps to safer surgery checklist and we foundthis was completed for all surgical patients. Checksincluded recording the number of swabs, sutures andneedles during the procedure. Checklists we reviewedhad been completed correctly. A WHO checklist wascompleted for patients who had vasectomy treatment.Audits we reviewed from the past year showed staffwere consistently compliant with the WHO checklistwith scores of 100%.

• The service had protocols in place to deal withhaemorrhage.Staff had received scenario-based trainingand staff we spoke with were able to describe what theywould do in the event of a haemorrhage situation. Therewas a haemorrhage kit within the clinic and theorganisation had a haemorrhage policy in place. Therewas a dedicated blood fridge at the centre in the eventof a major haemorrhage incident.

• For general anaesthetic treatments, the staffing levelsincluded the surgeon, anaesthetist, one ODP, aperioperative nurse and two health care assistants. Tworegistered nurses trained in airway management and ahealth care assistant managed patients in the recoverystage. For conscious sedation procedures, a registerednurse who had completed conscious sedation trainingwas present during treatment, with the surgeon and twoheath care assistants. However, we could not be assuredthat staff had the appropriate skills, as the risk registerhighlighted that staff records showed not all staff hadnot completed ILS training. Information providedfollowing inspection identified that there had beenoccasions where staff working in the treatment roomhad not received the appropriate skills and training (forexample ILS training and conscious sedation recoverytraining). This had been entered onto the risk register on2 September 2019 with identified actions to address therisk and improve oversight. We were assured that sincethe issue had been identified all staff who worked withinthe treatment and recovery area had the appropriateskills and training.

• Patients had a blood test to determine their rhesusstatus and blood group. Patients who had a rhesusnegative blood group were given an anti-D injection tohelp prevent any complications in future pregnancies.

• Patients were given a discharge letter documenting thecare and treatment given. If patients agreed a copy of

the letter was also sent to the patients GP. Patients weretold that in the unlikely event of any seriouscomplications following the procedure to share theinformation in the letter with other health careprofessionals.

• The home use of misoprostol in England was approvedby the government from 1 January 2019. Staffcompleted appropriate assessments with women whochose to self-administer the second stage of themedication (misoprostol) at home to ensure it was safeto do so. This option was only offered to women up tonine weeks and six days gestation. The first stage of themedication was taken at the clinic. Women wereprovided with a booklet which gave details on how totake the medication at home, and information on whoto contact if they needed further support or guidance.

Nurse staffing

The service had enough staff with the rightqualifications, skills, training and experience to keeppatients safe from avoidable harm and to provide theright care and treatment. Managers regularlyreviewed staffing levels and skill mix.

• The organisations ‘minimum clinical staffing levels’policy set out minimum clinical staffing levels at BPASand gave guidance on the minimum staff required, forthe different treatments offered. The treatment unitmanager was responsible for setting clinical staffinglevels at the clinic.

• At the time of inspection, there were three vacancies,one for deputy clinical nurse, one health care assistantand one operating department practitioner (ODP). Theorganisation was actively advertising for the posts.

• Fifteen registered nurses/midwives were employed atthe time of our inspection. Regular bank and agencystaff were used to cover vacant and unfilled positions,apart from the deputy clinical nurse position, which wasviewed as an internal development opportunity.

• Rotas were completed locally which meant managershad the oversight and empowerment to match skillssets to the patient treatments planned.





• Staff from another clinic could be called upon if therewere staff shortages and vice versa. This meant the clinichad the option of calling on experienced staff fromwithin the organisation if they required.

Medical staffing

The service had enough medical staff with the rightqualifications, skills, training and experience to keeppatients safe from avoidable harm and to provide theright care and treatment.

• Medical staff were employed on both a substantivebasis and under practising privileges. Their recruitmentwas managed centrally by the provider. 'Practisingprivileges' is a term that is used in legislation anddefined in the Health and Social Care Act 2008(Regulated Activities) Regulations 2010 as: 'the grant, bya person managing a hospital, to a medical practitionerof permission to practise as a medical practitioner inthat hospital.

• Records we viewed demonstrated those medical staffhad up to date practicing privileges and general medicalcouncil certification for the surgeon. Records of medicalstaff practicing privileges were also held at head officeand the medical director had overall responsibility forthe management of medical staff.

• We reviewed the conscious sedation policy, and this wasin date and ratified. The policy outlined clear protocolsand processes for when conscious sedation could beadministered without an anaesthetist present. Therewere nurse practitioner staff trained in conscioussedation. We saw those staff members had completed aconscious sedation course.

• Medical staff also worked remotely to review patients’case notes and medical histories prior to signing theHSA1 forms and prescribing medications. HSA1 formsare for practitioners to certify their opinion on thegrounds for an abortion.

• At the time of our inspection there were no vacancies formedical staff.

Records

Staff kept detailed records of patients’ care andtreatment. Records were clear, up-to-date, storedsecurely and easily available to staff providing care.

• Patient records were both electronic and paper basedand contained detailed information on the patient’streatment journey. We reviewed 10 patients recordsfrom a variety of treatments and found they had beenfully completed, signed and dated and containedinformation, such as consultation notes,pre-assessment medical history, patient allergies,completed HSA1 forms and signed patients consent.

• Electronic patient records were password protected andpaper records were stored in a locked file. Paper recordswere kept for three years. Following this period, theywere archived for ten years in line with the recordsretention and disposal policy.

• Patient information could be accessed through theBPAS information system, which meant patients couldbe seen at different clinics without delays in access totheir information.

• During all consultations we observed patients wereasked if information could be shared with their generalpractitioner (GP) and this was only done if consent wasgiven.

• Five random patient records were audited monthly. Theaudits looked at the whole patient treatment plan andwhether all risk assessments and relevant informationhad been recorded. From February 2019 to July 2019 theoverall score was 100%. Any discrepancies withinpatient records were highlighted and actions suggested,which usually involved talking to the staff member andreminding them of the correct processes to follow.

Medicines

The service followed best practice when prescribing,giving, recording and storing medicines. Patientsreceived the right medication at the right dose at theright time. However, medicine management refreshertraining had not been effectively managed.

• Managers told us staff had to comply with the BPASMedicines Management Policy and Procedure. Thepolicy complied with the appropriate legislation andwith standards laid down by the relevant professionalbodies such as the Nursing and Midwifery Council(NMC).

• The organisation had recently updated and amendedtheir conscious sedation management policy (August





2019) in light of practices identified at another location.The organisation had removed permission for thepractice of drawing up sedation medication in syringesin advance of use. Staff we spoke with said they hadreceived communication and instructions to stop thispractice, and during our inspection we saw nopre-drawn medicine. Staff said this had happened in thepast, but since the revised policy the practice had beenstopped.

• Patient Group Directives (PGD) were in place for aselection of drugs. PGD’s provide a legal frameworkwhich allows some registered health professionals tosupply and/or administer specified medicines, such aspainkillers, to a predefined group of patients withoutthem having to see a doctor. At the time of inspection,we saw an up to date signed list of staff who couldprescribe and administer medicines using a PGD. PGDtraining was undertaken at head office. However, theworking party group meeting minutes of 21 August 2019,identified that the PGD folder contained two out of datePGD’s and that six monthly audits were not consistentlydated. Actions included updating the PGD audit tooland updating the PGD’s. We found the PGD’s were all upto date at the time of inspection.

• The service administered controlled drugs (CDs). Wefound CDs were stored in line with recommendedlegislation and all recordings we reviewed in the CDregister had been signed by two registered nurses. Thelevels of stock entered, were completed fully and werecorrect.However, we saw there had been incidents inthe past when the register had not been correctlycompleted, and this had been highlighted during theroutine checks on the CD register by the organisation.The keys for CDs were held by the operating departmentpractitioner. CDs were ordered by the area manager anddeputy clinical matron.

• The Home Office Controlled Drugs Officer conducted ameeting at Streatham in July 2019 and reviewed thehistory of BPAS Streatham and the services provided.The officer discussed the CDs that were used and thepathway from requisition to delivery. This meetingincluded a review of local medicine management, therecording of drugs and audits as well as the BPAS unitdashboard. The review included a full building check,including the back garden and how secure the premises

were. This included viewing CCTV footage and localpolicies and hard copies of the order forms and spotchecks of drug numbers to register. The outcome of thereview meant the clinic had their licence renewed.

• The clinic completed monthly medicine audits, wherechecks were made on correct practices for recordingCDs, medicine and room fridge temperatures, andevidence that drugs received matched drugs ordered.The July audit showed there were discrepancieshighlighted on ‘times drugs given’. There were somemissed fridge temperatures in the June audit, and thedaily CD checks identified a discrepancy of total CDdrugs at the end of the list. This had been reported as anincident and investigated appropriately. The Augustaudit showed there were no discrepancies with CD’s andthe new TUM had shared the findings with staff.

• Staff had received training for the management ofmedical gases and at the time of inspection 100% ofstaff had completed their training. However, at the timeof inspection, implementation of formalised medicinemanagement training or refresher training was still inprocess and this had been entered onto the risk registeron 8 September 2019. The revised MedicinesManagement Policy had launched on the 29th August2019, with an accompanying email from the director ofnursing that stated medicines management trainingwould be available to access as an online module soon.The clinic was in the process of organising refreshertraining and this was due to be completed by end ofOctober2019.

• Every month there was a full stock check of medicines.Staff had an index card where they signed out medicineswith a number and this was added to the patientrecords and helped the centre track and trace daily useof medication such as misoprostol.

• The government legalised/approved the home-use ofmisoprostol in England from 1 January 2019 for womenthat had not exceeded nine weeks and six daysgestation at the time mifepristone was taken. The clinicoffered patients this option, having conducted researchand studies of systematic reviews.

• The misoprostol (for home administration) was suppliedagainst a prescription and labelled appropriately. Thelabelling included the patients name, date ofdispensing, name of the medicine, directions for use,





precautions, and name and address of supplyingpharmacy. In addition, women were given informationon how to take the medication and patients recordsreflected that the medication had been supplied as atake home pack. The take home pack included contactdetails for patients in case they were worried or neededfurther support and guidance.

Incidents

The service did not always manage patient safetyincidents well. Staff did not always report incidentsand lessons learnt were not always shared with thewhole team.

• Incidents were reported through the services electronicincident reporting system and followed theorganisations client safety incidents policy andprocedure. This described the monitoring and reportingprocess. Incidents were discussed at the quality and riskcommittee and this fed into the clinical governancecommittee.

• During the inspection, we were not assured incidents ofall levels were routinely being reported, investigatedand lessons learnt and shared with staff. The incidentreporting and sharing of information culture within theclinic was variable and not strong. Many staff we spokewith said they did not always report incidents as theyfelt there was a blame culture within the clinic, and theydid not always receive feedback of incidents reported.However, incidents were discussed in the morninghuddle and feedback from incidents, when reported,were sent via e-mail or given face to face.

• Staff could describe incidents and knew the processesto follow when reporting.

• We reviewed two local team meeting minutes, andthese showed no discussion had taken place on anyincidents reported. Incidents was not a set agenda itemduring local team meetings. However, incidents weredue to be discussed during the new working party groupmeetings, recently introduced by the new TUM, but, yetto be fully embedded into the service.

• The oversight of incidents at a senior level was a lotstronger, and we saw serious incidents, clinical incidentsand common themes and trends were discussed duringthe bi-monthly area managers meetings and clinicalgovernance meetings. Information and lessons learnt

from these meetings were disseminated to clinicsthroughout the organisation, and the treatment unitmanagers of each clinic were responsible for sharing theinformation with staff.

• In the last 12 months there were no never eventsreported. Never events are serious incidents that areentirely preventable as guidance, or safetyrecommendations providing strong systemic protectivebarriers, are available at a national level, and shouldhave been implemented by all healthcare providers.

• During the reporting period there were two seriousincidents reported. Serious incidents were investigatedusing a root cause analysis approach by theorganisation’s patient safety team.We were providedwith information relating to the two incidents andfound, although they had been thoroughly investigated,several agreed actions had not been updated or date ofcompletion, added on the reports.

• A total of 76 clinical incidents were reported from April2018 to April 2019.

• The duty of candour (DoC) is a regulatory duty thatrelates to openness and transparency and requiresproviders of health and social care services to notifypatients (or other relevant persons) of certain ‘notifiablesafety incidents’ and provide reasonable support to thatperson. The DoC was applied for both serious incidentsand for patients that were transferred to an NHShospital. These patients were invited into the clinic for ameeting.

Safety Thermometer

The service used monitoring results well to improvesafety.

• Staff completed a patient’s venous thromboembolism(VTE) assessment on all records we viewed. In the pastyear the service had completed 2388 VTE assessmentsfor those patients who underwent surgical terminationof pregnancy.

• The number of patients who underwent an abortionafter 20 weeks gestation who were risk assessed for VTEin the last 12 months totalled 441 patients.

• A local integrated governance dashboard was updatedevery month. Information collected included safetyinformation which could be shared with staff.





• There were no incidences of hospital acquiredMeticillin-resistant Staphylococcus aureus (MRSA),Clostridium difficile (c.diff) or E-Coli in the previous 12months.

Are termination of pregnancy serviceseffective?


We rated effective as requires improvement.

Evidence-based care and treatment

The service provided care and treatment based onnational guidance and evidence-based practice.

• Care and treatment was delivered in line with currentlegislation and nationally recognised evidence-basedguidance. Policies and guidelines were developed inline with professional bodies such as the Royal Collegeof Obstetricians and Gynaecologists (RCOG),Department of Health Required Standard OperatingProcedures (RSOP), Royal College of Anaesthetists, andthe National Institute for Health and Care Excellence(NICE) guidelines. We reviewed policies such as themanagement of the deteriorating or septic client andfound references had been made to: NICE CG50: Acutelyill adults in hospital: recognising and responding todeterioration July 2007 and NICE guideline NG51:Sepsis: recognition, diagnosis and early management.Effective processes were in place for policy ratification.Each clinical review and policy guidelines were reviewedby a responsible officer and validated by the clinicalgovernance committee. Policies we reviewed wereratified and in date.

• At a local level, there was systems to monitor patientoutcomes, such as failure rates, complaints, patientexperience and prevention of infections andcomplications. This was in line with RSOP 16‘Performance standards and audit’.

• In accordance with RCOG and RSOP 13 ‘Contraceptionand sexually transmitted infection (STI) screening’patients were screened for sexually transmittedinfections and offered contraceptive options duringconsultations and assessments for treatment. RSOP 13states a woman should be offered testing for STI and all

methods of contraception, including long actingreversible contraception (LARC) immediately afterabortion. During our inspection we observed staff offerthese options to patients throughout their treatmentwith the service.

• All patients were offered counselling servicesthroughout their treatment journey and this was in linewith RSOP 14: ‘Counselling guidance’.

• The management of fetal tissue policy was in line withThe Human Tissue Authority 2009 Code of practice 5:disposal of human tissue HTA London. We foundpatients were provided with information about disposalof pregnancy remains, so they could make a choicebefore treatment began.

• Discharge information was provided to patients in theform of a booklet. Information, such as possiblecomplications and support and guidance for anyconcerns were supplied. There was a 24-hour telephonenumber, patients could use if they needed support onany concerns they had.

Nutrition and hydration

Staff gave patients enough food and drink to meettheir needs and improve their health.

• Patients received an information booklet ‘My BPASGuide’ which provided information on fasting beforetreatment. Information on eating and drinking beforetreatment was available on the organisation’s website.We saw staff checked the last time patients ate or drankduring their admission appointment on the day ofsurgery.

• Patients were offered water, hot drinks and biscuits afterthey had received treatment. People who attended withpatients had access to hot and cold drinks.

Pain relief

Staff assessed and monitored patients regularly to seeif they were in pain and gave pain relief in a timelyway.

• Staff assessed and monitored patients pain regularly toensure they were comfortable and not in pain. Womenwere routinely offered pain relief such as non-steroidalanti-inflammatory drugs during surgical termination ofpregnancy.





• Staff assessed patients pain using a standard painassessment tool and by asking patients if they were inpain. The pain tool enabled staff to measure a patient’spain level by a scoring system. This was in line withRoyal College of Obstetricians and Gynaecologistsguidelines. Records we reviewed demonstrated painrelief was prescribed and administered correctly.

• Patients were given oral and written pain controlinformation as part of their discharge information pack.

Patient outcomes

Staff monitored the effectiveness of care andtreatment. They used the findings to makeimprovements and achieved good outcomes forpatients.

• RSOP16 states that outcomes of patients care, andtreatment are routinely collected and that the serviceshould have clear, locally agreed standards againstwhich performance can be audited, with focus onoutcomes. The organisation had a planned programmeof audit and monitoring. Audit outcomes and servicereviews were reported to governance committees suchas infection control and quality risk committees.Managers attended meetings with their area managerswhere audit outcomes were discussed. Treatment unitmanagers completed action plans for areas ofnon-compliance which were reviewed by theorganisations clinical department and quality riskcommittee.

• The organisation monitored performance outcomesmonthly using a clinical dashboard. Complication rateswere gathered alongside audited outcomes on waitingtimes for treatments, complaints and do not proceedrates.

• From April 2018 to March 2019 the clinic undertook 2388medical terminations and 441 surgical termination ofpregnancy procedures.

• Information provided from the organisation showedfrom April 2018 to March 2019 the do not proceed ratewas 6%, which meant out of 4750 consultations, 285patients did not proceed to treatment. From April 2018to March 2019 the did not attend rate was 10.5% whichmeant from 4712 termination of pregnancy procedures,493 patients did not attend for treatment.

• From April 2018 to February 2019, there were 11 clinicalcomplications reported, such as continuing pregnancyafter treatment and retained products of conception.

• The service monitored complication rates. Informationwe reviewed showed between April 2018 to March 2019,for major surgical complications, the rate was less than1%. Complications included haemorrhage, andperforation of the uterus. For minor surgery, the rate wasless than 2%. For medical abortion complications, therate was less than 1%. Complications includedincomplete abortion and two cases of continuingpregnancy.

• The service offered long acting reversible contraception(LARC) and had a steady uptake rate of 21.4 LARC is amethod of birth control which provides effectivecontraception for an extended period without useractions. LARC was administered by the surgeon andnurses who had received and completed LARC training.The clinical commissioning groups who contracted theservice expected a LARC uptake rate of 30%. Initiativessuch as pre-consultation telephone calls to discussLARC options with patients had started to help improvethe uptake.

• Effectiveness of early medical abortion (EMA) wasmeasured by patients taking a pregnancy test posttreatment. When the pregnancy test was positive thepatient would be asked to attend the clinic wherefurther options would be discussed and agreed.

• We were not assured monitoring of audit informationand checks were fully robust or accurate. At the time ofour inspection the new TUM had introduced a morerobust IPC daily checklists, which included moredetailed areas for checks. This was in recognition thatthe old checklists were very basic and did not capturethe full criteria required to ensure a full and thoroughinspection of IPC practices had taken place at the startof the day. At the time of our inspection this had yet tobe fully embedded into the service.

Competent staff

The service did not always make sure staff werecompetent for their roles. Managers appraised staff’swork performance and held supervision meetingswith them to provide support and development,however this had been sporadic, and not consistent.





• Monitoring and oversight of staff records had not beenfully effective. Staff records were not fullycomprehensive, in terms of completed competenciesand training. It had been recognised by the TUM thatthere were inconsistencies between evidence held instaff records and recorded on line. This was beinglooked into with the training department andindividuals concerned.

• We found one staff record where certain competenciesfor the role they were employed for had not been signedoff since they started the organisation over three yearsago. This had been highlighted on the risk register.

• Two staff members had not completed the mandatorysafeguarding training, one since 2015. Due to the lack ofoversight and strong management of staff records, theorganisation was taking steps to address the situation,and the staff had been placed on the necessary courses.This had been highlighted in the local risk register.

• Due to the temporary management arrangements andthe lack of full-time substantive post of clinical nursemanager (CNM), most staff fed back they had notreceived regular one to one sessions and meaningfulappraisals for the best part of two years. However, withthe appointment of additional management staff therewere plans to start completing appraisals for those staffthat were outstanding. This was still in the process ofbeing implemented at the time of our inspection. Thecurrent appraisal rate was 85%. The organisationsmedical director conducted appraisals of employedmedical staff. We were told these were up to date andheld centrally within the organisation, however we hadnot seen evidence to corroborate this.

• There was a BPAS induction programme for nursing staffconsisting of 12 weeks of specialist training for their rolesuch as consent course, and health and safety. As part ofthe induction programme staff were sent to differentlocations. Area managers or senior clinicians signed staffmembers competencies throughout the 12 weekprogramme to ensure staff were trained and couldcomplete different aspects of their role.

• Staff completed external training for ultrasoundscanning. New staff completed a two-day face to faceultrasound scanning training external accredited course.Staff completed 50 ultrasound scans under thesupervision of a mentor who was an experienced

practitioner. Staff had to pass and be accredited for firsttrimester ultrasound scans before they could completesecond trimester training. Staff had to complete threecase studies as part of their course. Scans were auditedevery two years by the lead sonographer.

• The 24-hour support telephone line had skilled qualifiedmedical practitioners available, should patients needthe support and guidance.

• Oversight of processes to ensure agency staff had basiccompetencies to perform their role within the servicewas not fully effective. Recently the clinic had identifiedthat agency staff had not received immediate lifesupport (ILS) training and were only trained in level 2safeguarding. As a result, the clinic had asked for allagency staff certificates before they were allowed towork at the clinic. This had been escalated to seniormanagers within the organisation, and they were nowmaking checks on agency staff at a national level. At thetime of our inspection certificates were being collectedand only agency staff who had the correct set ofcompetencies were allowed to work at the clinic.

• The risk register stated that staff had not completedrefresher training for medicine management and werenot following the medicine management policy. Thepolicy stated that clinical staff and the TUM mustundergo training every two years. The register alsostated that nurses reported there was no formalisedtraining, and nobody had received refresher training. Ithad been highlighted, through an audit of medicalrecords, that the recording of information wasinaccurate. It was believed the lack of organised trainingmay have contributed to this. As a result, training hadbeen organised and was due to be completed by theend of October.

• We saw staff who provided therapeutic support topatients, were appropriately trained and wereexperienced staff. Staff who provided post abortioncounselling completed the BPAS Client Support Skillsand counselling awareness course and were competentwith the client care co-ordinator competenciesframework.

Multidisciplinary working

Staff worked together as a team to benefit patients.They supported each other to provide care andcommunicated effectively with other agencies.





• Staff worked well together to ensure patients receivedcare. Staff conducted morning huddles where thepatient list and clarification for job roles andresponsibilities were discussed for that day. Weobserved the theatre huddle with the surgeon,anaesthetists and nursing staff and found the meetingsallowed for open and frank discussions where everystaff member could contribute.

• The clinic had a service level agreement with a localNHS trust for unplanned emergency transfers. Theservice met regularly with the trust to discuss theagreement and to go through each patient transfer forshared learning. The clinic was due to host a visit from alead consultant from the trust for late procedures.

• Staff said they regularly communicated and workedtogether with local safeguarding services and patientsGP’s. We saw staff asked all patients if they could sharerelevant information with their GP. Where the patientgave permission, staff sent a copy of the discharge letterto the patient’s GP.

Seven-day services

Key services were provided six days a week to supporttimely patient care.

• BPAS Streatham opened five days a week including oneday at the weekend, with opening times starting at07.30am and closing at 6pm.

• Patients could access advice and support throughoutthe year from a free telephone helpline which wasavailable 24 hours a day, seven days a week.

Health promotion

Health promotion information was available.

• Patients were provided with oral and writteninformation on contraceptive methods including longacting reversible contraception (LARC) when they visitedthe clinic. Patients were also offered the choice to betested for sexually transmitted infections (STI) such aschlamydia and human immunodeficiency virus (HIV).

• A range of health promotional leaflets were availablethroughout the clinic, providing advice on choosing hebest methods of contraception, and where to get furthersupplies.

Consent and Mental Capacity Act

Staff we spoke with were aware of theirresponsibilities for obtaining consent for treatmentand their roles and responsibilities under the MentalCapacity Act 2005 (MCA).

• Staff understood the relevant consent and decisionmaking requirements of legislation and guidanceincluding the Mental Capacity Act (MCA) 2005 and theChildren’s Act 1989 and 2004. Staff were supported bythe organisations consent to examination treatmentpolicy when obtaining patient consent.

• During our observations, staff asked for patient consentat various stages throughout the patient’s treatment.Written consent was obtained from the records wereviewed. There were different consent forms for eachdifferent type of treatment. Staff also explained the risksassociated to treatment and asked patients to confirmthey fully understood procedures before gainingconsent.

• Patients were given time to reflect and consider eachtreatment option, even for those treatments that werecompleted on the same day. For example, for medicalabortions patients had time to read through informationthey were given whilst waiting for the two remotedoctors to legally authorise the termination ofpregnancy. This allowed time for women to considertheir options before making an informed decision.

• Patients were given time on their own with the nurseprior to treatment to ensure they were seeking abortionvoluntarily.

• Patients who could not give consent or patients wholacked capacity were referred to the relevant NHSorganisation so that an independent mental capacityadvocate could be appointed.

• Staff fully understood Fraser and Gillick competencies.Gillick competence is concerned with determining achild’s capacity to consent and Fraser guidelines areused specifically to decide if a child can consent tocontraceptive or sexual health advice and treatment.Staff we spoke with understood the principles and thatthey should be applied when obtaining consent forpatients, under the age of 16 and used a specific Gillickcompetence and Fraser guidelines assessment form.





• The clinic conducted consent audits as part of themonthly consultation feedback audit, and informationwe reviewed showed staff consistently scored 100%.This information was fed into the monthly clinicaldashboard.

• Consent training was part of the induction programmeand consisted of a one-day course and shadowingexperienced trained staff on 20 consenting procedures.Staff records we reviewed showed staff had completedthis training.

Are termination of pregnancy servicescaring?

Good –––

We rated caring as good.

Compassionate care

Staff treated patients with compassion and kindness,respected their privacy and dignity, and took accountof their individual needs.

• Staff treated patients with kindness, dignity andcompassion. Staff took time to get to know patients andtreated all patients as individuals. A patient we spokewith commented staff “Made me feel comfortable andwere kind to me”. Another patient said, “Staff were verywarm and made me feel welcomed”.

• Staff treated all patients in a respectful and professionalmanner and were non-judgmental.

• During intimate care and examinations, patient’s privacyand dignity was respected. Consultations wereconducted in private rooms and patients were providedwith blankets when undergoing treatment to coverthemselves with. Patients dignity was respected whenthey were transported from the treatment room to therecovery area.

• We reviewed the client satisfaction report from April2019 to July 2019. The clinic scored 100%, for whetherpatients were treated with dignity and 100% and forwhether they were given enough privacy. 100% ofpatients said they had been listened to and 100% ofpatients said they had confidence and trust in the staffwho treated them.

• Patients had a private area for changing prior to surgicaltreatment.

Emotional support

Staff provided emotional support to patients tominimise their distress.

• Staff understood the impact a person’s care andtreatment could have on their wellbeing and providedemotional support to help reassure them. A client careco-ordinator was always available to speak with anypatients who required additional emotional supportduring the pre-assessment stage.

• Staff checked with patients if they had someone tosupport then or accompany them home after treatment.We saw staff checked with patients that they had thissupport prior to any treatment.

• Staff offered pre and post counselling services to allpatients. Patients were provided with information aboutto access a 24-hour helpline and we observed this wasoffered to all patients during our inspection. Patientswere also signposted to specialist bereavementcounselling services at local NHS trusts.

Understanding and involvement of patients and thoseclose to them

Staff supported and involved patients to makedecisions about their care and treatment.

• Staff communicated well with patients and made surethey understood their care and treatment. They gavepatients the opportunity to ask questions about theircare throughout the different stages of treatment. Staffexplained procedures clearly and confirmed withpatients that they understood what was happening.Patients we spoke with said they felt they had beeninformed of all risks and what the treatment involved.Patients said they had been given time to consider alltheir options.

• The client satisfaction survey from April 2019 to July2019 showed that 98% of patients felt they had beengiven enough information about aftercare and 100%said they were involved in decisions about theirtreatment. All patients who provided feedback said theyhad been given clear explanations about theirtreatment. However, during the inspection severalpatients said staff could do better in explaining the





waiting times and one patient commented that thewhole process had been very confusing, they had beentold about the steps of the treatment but, not why it washappening. However, we did speak with several patientswho commented they had been waiting for a while andthis had made them upset and anxious.

• Women were given clear information on the supply ofthe second medication (misoprostol) to to take awayand administer at home. We observed women givenclear instructions on how to administer the medication.Staff asked patients if they needed to ask questions andasked if they understood all the instructions. Staff thenprovided all the information in a booklet andpinpointed information in the booklet which wasrelevant to their treatment.

• Staff made patients aware that information would beused for statistical purposes by the Department ofHealth, but the information would be anonymised.

• Discussions on costs were hardly discussed as mostpatients were NHS funded. However, information oncosts were displayed on the organisation’s website.

• During our observations staff disussed and gave optionsto patients on the disposal of pregnancy remains.Patients were made aware of what choices there werewhen following this pathway.

• Staff provided patients with an aftercare booklet, whichgave details of a telephone advice line and informationon the treatment they had.

Are termination of pregnancy servicesresponsive?


We rated responsive as requires improvement.

Service delivery to meet the needs of local people

The service planned and provided care in a way thatmet the needs of local people and the communitiesserved.

• The service reflected the needs of the population servedand managers were able to plan and organise servicesto meet the changing needs of the local population. Ifthere was a peak in demand the service was able toadjust lists and opened on bank holidays.

• The facilities and premises were appropriate for theservices being delivered. The clinics were easilyaccessible and local transport facilities were good.

• Patients were able to book appointments via BPAScontact clinic, available 24 hours a day. Patients weregiven a choice of appropriate location dependent ongestation and medical assessment.

• The service had recently introduced a vasectomy clinic,which was in the early stages at the time of inspection.The uptake had not been high, and the service wasassessing the impact this had on the other serviceswithin the clinic, which had to be changed forvasectomy treatments. The service could not explainwhy there was such a low uptake of the service andwere currently working with local CCG’s to explore waysof improving the demand.

• The service attended regular meetings with the clinicalcommission groups (CCG) who contracted BPASStreatham.

• Three members of staff were able to fit long actingreversible contraception (LARC) and the clinic was in theprocess of waiting for more dates of future courses forother staff to attend.

• Due to the introduction of patients being able to takethe second stage of medical abortion at home, theservice had made adjustments to the surgical list sothose patients who wanted an intrauterine device(IUD)fitted could be seen.

Meeting people’s individual needs

The service was inclusive and took account ofpatients’ individual needs and preferences. Staffmade reasonable adjustments to help patients accessservices. They coordinated care with other servicesand providers. However, there were problems with theexternal translation service.

• Staff had completed ‘welcoming diversity’ trainingduring their initial induction and this helped staffunderstand and recognise different cultural needs andbeliefs.

• There was an interpreting service available for thosepatients for whom English was not their first language.However, we were told of a recent complaint receivedfrom a GP, where the patient who had used the service





during a consultation with BPAS, was giveninappropriate information from the interpreter, inrelation to their religious beliefs. Staff told us there hadbeen occasions when interpreters were not purelyfocused on the service they should have been providing,for example they were washing up when translating orbackground noises of children crying could be heard.The organisation was aware of the issue and was in theprocess of engaging more closely with the service torectify the problems. However, at the time of ourinspection the clinic was still using the external service,but staff were asked to report any incidents to thetreatment unit managers.

• Patients were given the choice of making an informeddecision about the disposal of pregnancy remains. Fromrecords we reviewed and observations of consultations,staff provided this information to women in a sensitivemanner.

• Due to the same day consultation and treatmentoptions the organisation recognised this took away the‘thinking time’ for women regarding LARC options.Therefore, the local CCG had commissioned the clinic tostart pre-consultation telephone calls to discusscontraception options and give women more time toconsider their options.

• The clinic had recently started to offer to patients thehome use of misoprostol. However, we found womenwere not offered the choice of returning to the clinic totake the second tablet if they wanted to. For thosepatients who were not confident or needed reassurancethe clinic did not offer this option, unless staffrecognised patients who were not confident orcomfortable.

• The clinic paid for hotel accommodation for thosepatients who needed to be seen by the service within alimited time frame and lived in another part of thecountry. This option was available for those patientswho could not afford additional expenses.

• The service had information leaflets available indifferent languages and braille. The central bookingsystem allowed one-hour slots for those patients whocould not speak English. A hearing loop was availablefor use by people with hearing aids, and a sign languageinterpreter could be booked if patients required.

• Patients were able to request a chaperone andinformation was displayed throughout the clinic.

• Women seeking abortion for fetal abnormality wereprovided privacy in a separate room and their partnerwas able to stay with them throughout their treatment.

• The clinic had private rooms to accommodate thosemore vulnerable patients and patients under the age of18 years of age.

• The clinic offered access for disabled and wheelchairusers. There was a spacious lift to assist patients whoneeded treatment on the first floor.

• We inspected the satellite clinic in Southwark. The clinicwas based within a healthcare clinic, and we found theroom used by the organisation was based next door to anew born baby clinic. This meant that duringconsultations we could hear new born babies crying.This was not a suitable arrangement in terms of privacyand sensitivity for patients. Staff told us that they hadraised this as an issue, but the health clinic could notprovide an alternative room.

• Pregnancy remains following surgical termination wereindividually packaged, labelled and stored andcollected for appropriate disposal in line with HumanTissue Authority guidelines. There was a process forindividual storage of pregnancy remains when patientsrequested this to enable private burial, cremation or inthe case of criminal investigations. in a freezer beforecollection. The service kept records and logs of thosepregnancy remains.

• Staff made reasonable adjustments to help patientsaccess the service and coordinated care with otherservices for those patients who required further support,for example, patients with pre-existing physical andmental health conditions.

Access and flow

People could not always access the service when theyneeded it. Waiting times for surgical treatments,meant patients did not always receive care andtreatment promptly.

• Patients could access the service through GP referral,self-referral or family planning clinic. Contact could bemade via telephone, e-mail or text. Whilst women





receiving medical abortion had timely access to initialassessments, test results, diagnosis and treatment, notall patients could access care and treatment for surgicaltermination in line with national guidance.

• The Department of Health Required Standard OperatingProcedures (RSOP11) states that women should beoffered an appointment within five working days ofreferral and they should be offered the termination ofpregnancy within five working days of the decision toproceed.

• BPAS’ capacity manager had an overview ofappointment availability and worked with the treatmentunit managers amending templates and addingappointments when necessary.

• Information we received from the organisation showedthat from the period September 2018 to August 2019,the number of patients seen within 10 days fromconsultation (decision to proceed) to treatment was:

• 95% for early medical abortion patients: 2037 patients intotal. 1918 patient were seen within 10 days whichmeant 5% were not seen within 10 days. The averagewait was two days. 1223 patients chose same dayconsultation and treatment.

• 69% for surgical patients under 14 weeks gestation:1506 patients in total, 1030 patients seen within 10 days,which meant 31% of patients were not seen within 10days. (Average wait day was nine days).

• 46% for surgical patients above 14 weeks gestation: 963patients seen. 440 patients seen within 10 days, whichmeant 54% of patients were not seen within 10 days.(Average wait day was 15 days)

• We reviewed the treatment service availabilityschedules for July and August 2019 and found forsurgical termination procedures, some patients hadbeen waiting for 20 days. The information provided didnot include specific information as to the reasons fordelay (such as treatment availability, patient choice,repeated cancellations or did not attends).

• The BPAS reporting systems had not kept up with theadvances in appointment offerings, and therefore, thereporting systems were sometimes flawed. While theservice could look into individual patient data and thereason behind the patient’s waiting time (choice versusavailability), where a specific note had been made, theywere unable to pull the information together to form a

report which would show this for all patients at cliniclevel. The organisation was also unable to record thereason for the delay. However, on our request, theorganisation had looked into some of the individualrecords for BPAS Streatham, where longer delays hadbeen noted, and reasons such as, patients cancellingthe appointment, needing to arrange childcare, patientunsure of decision, arranging travel, wanting treatmentat a clinic-often not in their home town and patientforgot to go to appointments were recorded.

• BPAS provided commissioners with quarterly activityreports for their particular commissioning groups whichincluded waiting times.

• BPAS Streatham provided standby appointments, whichenabled them to make the best use of any do not attend(DNA) appointments. The clinic had a large number ofDNA and ‘cancelled on the day by patients’, and as aresult had never had to decline treatment on the day toany patients on standby for a general anaestheticappointment.

• At busy periods of the year the service adjusted lists byreducing conscious sedation treatments to incorporateadditional general anaesthetic treatments, as otherproviders operated lists throughout the London regionfor conscious sedation.

• BPAS Streatham had opened on bank holidays toensure capacity for late surgical terminations ofpregnancy.

• Patients we spoke with during the inspectioncommented on the length of time they had waited onthe day at the clinic. Some of the delays occurred whileremote doctors completed the HSA1 forms. Patientswere allowed out of the clinic, during the time of waitingfor their treatment. We noted most of the complaintsreceived at the clinic centred around waiting times.

• The client satisfaction report from April 2019 to July2019 showed the lowest score for patient satisfactionwas related to ‘clients seen within 30 minutes of theirappointment time’. Waiting times scored the mostpercentage of disagreement than any other questionsasked in the survey.

Learning from complaints and concerns





It was easy for people to give feedback and raiseconcerns about care received. The service treatedconcerns and complaints seriously, investigated themand shared lessons learned with all staff.

• People were encouraged to raise concerns to theservice. Information about how to give feedback wasavailable throughout the service as well as postersabout how to make a complaint or give feedback. The‘My BPAS guide’ given to all patients who completedtreatment contained information on how to make acomplaint.

• The complaints and client feedback policy andprocedure laid out specific timelines and formalprocesses in how a patient’s complaint should behandled. The treatment unit manager at Streatham wasthe first point of call to resolve issues raised at the clinicand staff were encouraged to diffuse any complaintslocally where possible. Patients wishing to make aformal complaint were referred to the clientengagement manager and acknowledged within threedays. The timeframe for a full response to be made was20 working days.

• The clinic had received 13 formal complaints within thereporting time period of April 2018 to March 2019 and allwere responded within the 20 day time frame.Complaints were logged onto the electronic incidentreporting system and rated low or moderate. Thecomplaints log we reviewed showed action had beentaken against each complaint.

• Changes of practices at the clinic, as a result of acomplaint around waiting times, now meant thatpatients were instructed to ‘arrive’ at a certain timerather than being told their ‘appointment’ was at acertain time. Patients were told that their arrival timedid not necessarily mean they would be seen at thattime.

Are termination of pregnancy serviceswell-led?

Inadequate –––

We rated well led as inadequate

Leadership

Not all the leaders demonstrated the skills andabilities to run the service. They did not alwaysunderstand and manage the priorities and issues theservice faced. They did not always support staff todevelop their skills and expertise.

• Leadership at a local level did not always support thedelivery of a quality sustainable service. There was alack of effective oversight of staff competencies, localrisks and robust auditing tools. Relationships betweenmanagers and staff was not unified.

• The structure of the leadership team at the centre,comprised of a treatment unit manager (TUM), who hadoverall management of the centre. They were supportedby a clinical nurse manager who managed the clinicalstaff and a client care manager who managed patientcare staff. There was an area nursing manager whovisited the clinic and provided clinical support for nursesand clinical managers. An operations area managermanaged the TUM and several other locations within aspecific region. They were managed by the associatedirector of operations.

• At the time of our inspection the centre had beenmanaged by a temporary (TUM) for the past 18 months.They worked a four-day week from Sunday toWednesday at Streatham. In April 2019 the service hadrecruited a new TUM, and they were still in theirprobationary period at the time of our inspection.

• We found there were fractious working relationshipswithin the local leadership management team and thisimpacted on effective leadership within the centre.There were different management styles, which meantactions required to manage risks, and qualityimprovements were inconsistent, lacked clarity andclear direction. This led to staff being confused as tohow the service was being managed. Most staff saidthere was no balance in the style of management. Stafftold us there was a heavy top down approach fromcertain managers within the organisation.

• However, staff told us the culture had started to changewith the new TUM and clinical nurse manager. Stafffound them supportive, accessible and approachableand willing to offer guidance and listen to them. Theyfelt they understood priorities and issues the servicefaced and the development and training they required





to undertake their role. There was high praise from staffabout the support the area midwife provided. Staff saidthe main directors who visited the service wereaccessible and took time to speak with staff.

• Managers could access a leadership and managementprogramme and first line managers training, whichcovered managing staff absence and recruitment. Thenew CNM had recently attended training for managingabsence and sickness.

• The service ensured a record was maintained of thetotal of termination of pregnancy proceduresundertaken. The clinic displayed the certification ofapproval issued by the Department of Health in thereception area of the service.

Vision and strategy

The service had a vision for what it wanted to achieveand a strategy to turn it into action, developed withall relevant stakeholders. However, staff did not fullyunderstand it.

• Although the service had a vision and strategy, at a locallevel staff were unsure of what it was. Staff were morefamiliar with the values of the service; compassionate,courageous, credible and committed to women’schoice. From observations, we saw staff incorporatedthe values in their everyday working role. Managers weremore familiar with the corporate strategy and businessplan. Information on the services strategy and visionwere accessible to all staff on the services intranet.

• The service made sure that staff provided TOP care inline with the Royal College of Obstetricians andGynaecologists (RCOG) and other professional bodies.Best practice was incorporated in policies andprocedures we reviewed and demonstrated in the waystaff delivered care and treatment.

Culture

Staff did not always feel respected, supported andvalued. The service had an open culture for patientsand families, so they could raise concerns withoutfear, but staff did not always feel they could.

• There was a negative culture and disconnect betweensome of the managers and staff within the centre. Moststaff we spoke with, told us they felt the culture wasreactive rather than proactive, with a culture of blame

and harassment and this had created an unsupportiveand demoralising environment at the centre. Staff toldus they were unable to express themselves andchallenge without fear of retribution. Staff believedsome conversations they had would be used for‘self-gain’ or ‘self-importance’ due to certainmanagement styles. As one staff member said, ‘If youraise concerns then you have to face the consequences.I have learnt to keep quiet’.

• Staff praised the new TUM and the CNM on theirsupportive, open and transparent style of managementthey had adopted in the short space of time since beingin their respective roles. They felt the culture was moreharmonious since they had started their roles, and theyfelt listened to. Staff fedback that the two managersoften asked about their wellbeing, for example, theychecked to ensure staff had taken their breaks, weremore flexible in their approach and felt there was amore settled happier environment. The two staffmembers were in their probationary period as per BPASpolicy.

• Most staff we spoke with enjoyed their role and workingfor BPAS as an organisation. Clinical staff worked welltogether and were supportive of each other as a team.Clinical and administrative staff had a good patientcentred approach.

• The new TUM had created a working party group, ameeting to recognise good working practices, andrecognise ways in which people could work together in abetter way. Audit findings were shared at this meeting.However there had only been one meeting and soshared learning and staff participation in qualityimprovements had yet to be fully embedded into theservice. Information provided after the inspectionsupported the working party group as a good way toengaging with staff and managing feedback. We wereinformed these meetings would continue.

• Clinical staff we spoke with said they had just recentlyreceived an appraisal, and this was with the new TUMand area nursing manager. They said the appraisaldiscussion had been good and career developmentopportunities and training had been discussed. Moststaff said past appraisals had been sporadic and notentirely effective. Staff fed back they did not always feelvalued and they did not feel they had been developed.





• British Pregnancy Advisory Service (BPAS) is a not forprofit organisation, and approximately 97% of patientshad their treatment paid for by the NHS. Prices for feepaying patients were clearly advertised on the BPASwebsite.

Governance

Local leaders did not always operate effectivegovernance processes, throughout the service andwith partner organisations. Staff at all levels wereclear about their roles and accountabilities but didnot always have opportunities to meet, discuss andlearn from the performance of the service.

• The organisation had structures, processes and systemsof accountability in place, that related to national BPASstructures and committees.

• The governance structures at local level fed into thecorporate level structure, with the area managersholding bi-monthly meetings with the TUM to discusscapacity and waiting lists, audits, incidents, complaints,patient feedback, risk and other relevant items thatneeded dissemination or escalation. Outcomes fromthese meetings were fed into the operational activitycommittee and quality and risk committee meetingswhich were held every four months.

• However, local governance arrangements were not fullyeffective. The identification of risks and improvement ofquality was not managed well. There had been a lack ofmonitoring of staff mandatory training and this meantinformation fed into the monthly dashboard was notentirely accurate. It had been identified that audit toolsused for infection control checks and medicinemanagement were not effective.

• The dashboard included headings such as, appraisals,medicines management, clinical supervision andproviding a competent workforce. The dashboard wasrag rated green, amber and red, with red highlightingareas of concern. We were not assured accurateinformation was reflected on the dashboard. Forexample, providing a competent workforce wasconsistently green rated for all the dashboards wereviewed. However, we highlighted staff who had nothad competencies signed off and staff who had notcompleted mandatory training within a specified

timeframe. Therefore, we were not assured thatinformation used in reporting, performancemanagement and delivering quality care was alwaysaccurate or reliable.

• We saw meeting minutes from the area managersmeeting and the clinical committee group. Bothmeetings had standardised set agendas whereincidents, patient complaints, clinical outcomes andoperational issues were discussed. At a local level thisstandard was not applied. The clinic held teammeetings, but there was no structure or set agenda tothese meetings. We were told they were heldapproximately every six weeks. Minutes we reviewedshowed no standardised topics were covered, such asincidents, complaints or lessons learnt. Informationprovided post inspection stated that a more formalteam meeting agenda template would be implementedby the area manager for use in all the London area units.

• The new TUM had created a working party group, ateam of clinical staff to identify new working practices toimprove assurance checks and non-complianceidentified, for example, in past infection control audits.Results included updating infection control tools forstaff to use for their daily checks. We saw information onthe outcome of working party group meeting wasshared with staff throughout the clinic. The newupdated infection control tools were in use during ourinspection. There had only been one working partygroup meeting at the time of our inspection and thishad taken place on 21 August 2019.

• The manager was aware of the requirement to notify theCare Quality Commission (CQC) and Department ofHealth in writing should a woman die within 12 monthsof using the service and of other statutory notificationsto CQC.

• The service delivered care and treatment in accordancewith the Abortion Act 1967. Patients were assessed forsuitability for an abortion during the consultation stage,by a registered nurse and client care co-ordinator. Theinformation was then sent electronically to two remotedoctors for review. If the doctors were satisfied andhappy to proceed, they would both electronically signthe form.





• The service audited the HSA1 forms by randomlyselecting five patient records per month. We reviewedaudits from February 2019 to July 2019 and found aconsistent score of 100%.

• There were suitable arrangements in place to ensurethose staff working under practicing privileges hadappropriate indemnity insurance under The Health Careand Associated Professions (Indemnity arrangements)Order 2014.We reviewed all staff records for thoseworking under practising privileges at the clinic andfound indemnity insurance was in place.

Managing risks, issues and performance

Systems were not effectively used to monitor andmanage performance effectively. Leaders and teamsdid not always use systems to manage identify andescalate risks.

• The organisation had arrangements for identifying,recording and managing risks, however these were notmanaged robustly at a local level.

• We reviewed the local risk register and found risks wereoutdated, did not have completion dates or actionstaken against them. The new TUM had recently takenover managing the risk register and had added risks notpreviously recognised. The risk register was scored witha red, amber and green RAG rated system.

• We found a risk raised in 2017, in relation to ineffectivetracking under 18 vulnerable adults resulting in lack ofsupport or referral for those at risk, with a due forcompletion date 2017, had not been completed and noupdate on the register. One risk had no date raised andno actions or date to complete the actions.

• We found a risk dated 2018 regarding staff failure tocomplete mandatory training that had a due date ofcompletion stated as May 2018. We found mandatorytraining was not fully monitored or managed well at thetime of our inspection.

• New recent risks had been added to the register (19August 2019) by the new treatment unit manager. Theseincluded, the unreliability of the scanning machine usedin the treatment room. Surgeons had reported that theimage was distorted and kept switching off duringprocedures. We were told this had been raisedpreviously with the treatment unit manager, but noaction had been taken. The new treatment unit

manager had added the risk to the risk register andactions showed a new scanner had been purchased. Atthe time of our inspection the clinic was still awaitingthe arrival of the machine. There had been no reportedincidents where patient safety had been compromised.We were told another scanner in the clinic could beused if necessary.

• Another risk related to the scavenger system, which wasnot connected to the treatment room. A scavengersystem collects and removes waste gases from thepatient breathing circuit and the patient ventilationcircuit. This had been identified by the new TUM andescalated. Actions included updating the daily checklistand organising a scavenger system to be delivered fromanother clinic. At the time of our inspection the clinicwas still in the process of having this delivered.

• Managers had the ability to monitor performancethrough monthly dashboards, however, we were notassured that this had been undertaken in a robustmanner. We found several concerns that werehighlighted during the inspection, such as poormandatory training monitoring, lack of incident sharing,lack of oversight of staff competencies that had onlyrecently been recognised.

• At a corporate level, new director’s in post hadintroduced a monthly risk steering group to discuss highlevel risks. There was a quality and risk committee whomet on a quarterly basis and information was fed intothe clinical governance committee meetings. We sawmeeting minutes of June 2019 which showed risks andactions taken had been discussed.

Managing information

The service did not always collect reliable data andanalysed it. Staff were not always provided with thedata they needed, in easily accessible formats, tounderstand performance, make decisions andimprovements.

• We were not assured there was a holistic understandingof performance which captured and integrated people’sviews with information on quality. Staff did not alwaysreceive consistent information on audit outcomes andthis had only recently been addressed through the startof the working party group meetings.





• The quality of information to measure performance wasnot always accurate and therefore, not reliable. Theorganisation had systems for clinics to reportperformance and quality information, however this hadnot been managed well locally, which had meantoversight was not fully effective. Therefore, we were notcertain valid, reliable and relevant information wasalways reported. The lack of identifying and acting uponrisks meant issues were not always identified and actedupon to improve the quality of care.

• There was a system in place to make sure HSA4 formswere submitted to the Department of Health inaccordance with the Abortions Regulations 1991. AnHSA4 form is the official notification of abortion andmust be submitted to the Chief Medical Officer within 14days. There was an online completion and submissionprocess in which the BPAS electronic system linkeddirectly with the Department of health system. BPASdoctors obtained a secure login and password from theDepartment of Health to use the service. However, theservice was not always sending the forms within thetime frame. The monthly dashboard often showed thesubmission of HSA4 forms as red rated. This meant thedeadline was not being met, and we were told this wasdue to doctors not always pressing the submissionbutton. Management had reinforced the message todoctors, but this seemed to be a persistent problem.

• The service had system to make sure HSA4 forms werecompleted appropriately to indicate when treatmentwas provided at home in instances where the secondmedication (misoprostol) was supplied to the patient totake away and administer at home. The service’s onlinesubmission system included a tick box for home useand staff would complete the HSA4 the following dayfrom administration to ensure accuracy. However, wewere not assured the forms were submitted within the14 day period as this was reflected on the monthlydashboard.

• Information governance training was mandatory, and atthe time of our inspection 79% of staff had completedtraining.

Engagement

Leaders and staff actively and openly engaged withpatients, the public and local organisations to plan

and manage services. They collaborated with partnerorganisations to help improve services for patients.However, locally more work was required to improvestaff engagement.

• Patients were given a feedback form to complete afterthey had received treatment. The forms were submittedto the client engagement manager for collation. Patientsatisfaction survey reports were reviewed at areamanagers meetings and the clinical governancecommittee.

• The overall patient satisfaction score was 9.4 out of 10for the months of April 2019 to July 2019. 100% ofpatients surveyed said they would recommend BPAS tosomeone they knew for similar care.

• Managers attended regular engagement meetings withlocal NHS trust with whom they have transferarrangements and local commissioners.

• The organisation conducted an annual staff survey;however, this was not specific to locations. We reviewedthe staff survey of 2018 and found the most improvednational highlights included ‘there was a willingness totry new things’, and ‘would recommend BPAS to friendsand family’. Bottom lowlights included ‘poorperformance and behaviour are dealt with effectively’,and ‘there are not enough staff for me to do my job well.’

• We were not assured that staff were actively engaged sotheir views were reflected in the planning and delivery ofthe service and in shaping the culture. However, the newtreatment unit manager was making steps to includeand engage nursing staff within the monitoring ofperformance and quality. However, this was in the earlystages and was not fully embedded into the service.

• There was a star of the month award where staffnominated other members of staff and the organisationprovided a free service for staff on advice for wellbeingand depression.

• The TUM told us the medical director asked for opinionsfrom staff and a two-day BPAS forum had been recentlyheld for staff to attend so they could provide their inputinto clinical issues.

Learning, continuous improvement and innovation





Staff were not always committed to continuallylearning and improving services. They did not have agood understanding of quality improvement methodsand the skills to use them.

• We did not see an embedded culture of learning,continuous improvement and innovation. In part thiswas due to negative relationships between seniorleaders at the centre. We found there was unreliable

data collection, a lack of effective oversight on stafftraining, and lack of feedback on reported incidents.This meant learning was not always shared to driveimprovements. Although recent changes had beenmade to make improvements in these areas, this hadyet to be embedded into the service. There was stillmore work to do.





Areas for improvement

Action the provider MUST take to improve

• The provider must ensure there are stronggovernance arrangements with strong leadership, toensure that risks and quality performance areidentified, mitigated and acted upon.

• The service must make sure there are effectivesystems for tracking and tracing staff mandatorytraining, including medicine management and sepsistraining.

• The service must make sure all staff records arecurrent and certifications on training andcompetencies are up to date.

• The service must make sure agency staff areimmediate life support trained and trained toSafeguarding level 3.

• The service must make sure all equipment iscalibrated and in good working order.

• The service must make sure the HSA4 forms aresubmitted on time.

Action the provider SHOULD take to improve

• The service should make sure there is an open andtransparent culture where staff feel safe to raiseconcerns.

• The provider should make sure there is a morerobust system for the reporting of incidents at alllevels and staff receive feedback on learning.

• The service should make sure patients have thechoice of whether the second medication ofmisoprostol is taken at home or at the clinic.

• The service should make sure there are robustarrangements in keeping PGD documentation up todate.

• The service should make sure formalised medicinemanagement training and refresher training asstipulated in the medicine management policy iscompleted by staff.

• The service should make sure the waiting time forlate stage surgical abortion is reduced in line withnational guidance.

• The service should make sure patients do not waittoo long on the day of their treatment.

• The provider should make sure they have assurancethat the external interpreting services havenon-biased non-judgmental staff.

• The service should make sure the vision and strategyof the organisation is embedded into the servicelocally.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activity

Termination of pregnancies Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

Regulation 17 HSCA 2008 (Regulated Activities)

Regulations 2014 Good Governance

How the regulation was not being met.

Local governance arrangements must support managersto assess, monitor and improve the quality and safety ofservices. They must support managers to mitigate therisks relating to the health, safety and welfare of serviceusers and others who may be at risk.

Regulation 17(1)(2)(a)(b)(c)

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


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