The Care Quality Commission
  • Hospital
  • Independent hospital

Archived: BPAS - Streatham

Overall: Requires improvement read more about inspection ratings

Leigham Clinic, 76 Leigham Court Road, London, SW16 2QA 0345 730 4030

Provided and run by:
British Pregnancy Advisory Service

All Inspections

5,6,16,18 September 2019

During a routine inspection

BPAS Streatham is operated by British Pregnancy Advisory Service. BPAS Streatham provides medical and surgical termination of pregnancy services, feticide treatment, screening for sexually transmitted diseases, contraception advice, counselling and vasectomy procedures. The service provides surgical terminations up to 23 weeks plus six days gestation and medical abortions up to nine weeks plus six days gestation. Facilities include one treatment room, five consulting rooms a two stage recovery area, and a discharge area. There was an early medical unit based within a health centre in Southwark. Early medical abortion treatment and consultations in the early stages of pregnancy were offered in a private room at this facility.

The service provides termination of pregnancy, sexual health screening and family planning services. We inspected this service using our comprehensive inspection methodology. We carried out the unannounced part of the inspection on 5,6,16,18 September 2019.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

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

The main service provided by this hospital was termination 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. Local governance arrangements did not ensure the identification, mitigation and monitoring of risks or the improvement of quality. There was a fractious relationship between some leaders and staff, and staff did not always feel valued or supported. We were not assured information fed into the monthly dashboard was accurate.

  • The monitoring of staff mandatory training and competencies was not managed well. There was no formalised tracking until very recently, and this had yet to be embedded into the service. Not all staff had received an annual appraisal or regular performance reviews.

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

  • Waiting times from initial referral to treatment were not in line with Royal College of Obstetricians and Gynaecologists (RCoG) national guidance and Required Standard Operating Procedures (RSOP) 11: Access to timely abortion services. Patients could not always access the service when they wished. 54% of surgical termination of pregnancy patients above 14 weeks gestation, waited more than 10 days.

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

However:

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

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

  • Staff completed patient records accurately and stored them safely.

  • The service treated concerns and complaints seriously and investigated them. The service included patients in the investigation of their complaint.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with one requirement notice that affected BPAS Streatham. Details are at the end of the report.

Nigel Acheson

Deputy Chief Inspector of Hospitals

10 and 11 May 2016

During a routine inspection

Improvements were required to ensure a safe service was provided and that effective leadership supported this. This was because:

  • Procedures for recognising and responding to the deteriorating person had not been addressed in a timely manner.

  • Infection prevention control (IPC) procedures did not adhere to The Health and Social Care Act 2008, Code of Practice on the prevention and control of infections and related guidance or associated national guidelines.

  • Systems to manage and monitor the prevention and control of infection were not fully implemented and acted upon. The cleaning arrangements for the operating theatre were not specified and the floor was not to the required standard of appearance and cleanliness.

  • Attention was required for recording accurate information in the controlled drug register.

  • The storage of temperature controlled medicines and other medicines were not sufficiently safe.

  • The local governance and quality monitoring processes did not always identify and take actions to address shortcomings where best practice was not being adhered.

  • There was work to do to ensure effective working relationships across all staff grades, and that staff were able to see issues raised were addressed in a timely manner.

  • There was some engagement with the public and staff but a top down approach meant it was less easy to be innovative at a local location level.

However, positive aspects of the service were identified with regard to safety, effectiveness, responsiveness, caring, and leadership. This included:

  • Treatment was mostly delivered in accordance with professional guidelines, which were accessible to staff.

  • Audit and outcomes for clients were monitored to ensure effective pathways were achieved.

  • Training specific for individual roles was provided to staff to ensure they were able to meet the needs of the patients they cared for.

  • Staff ensured vulnerable individuals were referred to external agencies in line with safeguarding protocols.

  • Patients were offered appropriate pain relief, precautionary antibiotic treatments, and post-abortion contraceptives.

  • The privacy, dignity, and respect of patients was fully considered in all aspects of the consultation and treatment pathways. Patients’ choices were mostly respected and they had a chance to speak with a nurse or midwife on their own to make sure they were not being pressurised to make a decision.

  • Patients received information in a sensitive manner and were treated with kindness and compassion. Staff provided attention to their emotional and social needs.

  • The service was accessible and afforded flexibility and choice.

  • Complaints were minimal but where raised were responded to in a timely manner.

  • Performance targets were generally indicative of an efficient and responsive service.

  • Staff understood the organisational strategy and ethos.

  • Organisational governance arrangements meant there was some oversight of performance, incidents, and complaints.

  • Senior staff understood their responsibilities under the duty of candour regulation.

  • Whilst there was no local risk register, there was work in progress to identify location specific risks.

  • Staff were supported to develop their skills and were provided with service specific information through a range of methods.

  • People who used the service, as well as staff were encouraged to feedback on the service in order to make improvements.

18 February 2013

During a routine inspection

Staff were professional and discreet. People's privacy and dignity were respected through the use of private consulting, counselling and treatment rooms. People said "I was very happy with the treatment and care, it was good that I could have everything on the same day, I didn't want to wait any longer". People received information about treatment options available and the associated risks.

Care was planned with people to reflect their individual needs and ensure their well being and safety by trained and qualified staff. People said "the advisor was sensitive to my reasons for wanting a termination and they even moved my appointment time to help me".

Treatment was provided in a clean and appropriately equipped environment to enable staff to safely perform surgical procedures and minimise the risk of infection to people using the service. Services were routinely monitored and assessed to identify and minimise risks.

21 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

20 June 2011

During a routine inspection

People using the service receive good information booklets specially produced to help them understand what the service provides.

For those using the service encouragement is given to complete client feedback surveys following treatment. Results reported high satisfaction level for all those that have used the service.

The service was awarded the 'You're Welcome' quality accreditation in 2009. This involved input from young people that used the service making unannounced visits and doing 'mystery shopper exercises'.

Professional staff are present from time of a peron's first consultations to give counselling and professional support, this enables one to consider all options available. People are able to decide what is right for them without feeling under pressure, make their own decisions; they are able to change their mind at any stage up to the time of the procedure.

Individuals are informed on the things they should do prior to prepare for treatment where anaesthetics are used.

People have confidence in the service; it has built a reputation of supporting people with unplanned pregnancies for many years.

We heard that the service delivers the outcomes expected of it, the following comments received from those that had experienced treatment, 'Staff are so helpful and understanding,' 'Sensitivity was displayed by all involved in my treatment'.