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Archived: BPAS - Amersham

Amersham Hospital, Outpatients Department, Whielden Street, Amersham, Buckinghamshire, HP7 0JD 0345 730 4030

Provided and run by:
British Pregnancy Advisory Service

Latest inspection summary

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Background to this inspection

Updated 21 October 2016

BPAS Amersham is part of the national charitable organisation, British Pregnancy Advisory Service.

The clinic is located in a community hospital. BPAS Amersham is contracted by Chiltern and Aylesbury clinical commissioning groups to provide a termination of pregnancy service to women in Buckinghamshire.

The BPAS Amersham clinic provides consultations, medical abortions (up to 10 weeks gestation) and simultaneous early medical abortions ( up to nine weeks). The clinic is open weekly on Tuesday 8.30am to 6pm, Wednesday 11.30am to 7pm and Friday 9am to 1pm. Staff provide a satellite service from Aylesbury, Buckinghamshire twice a week.

Other services at the clinic include pregnancy testing, unplanned pregnancy counselling, abortion aftercare, sexually transmitted infection testing, contraceptive advice and contraception supply. Between January 2015 and December 2015 the service carried out 481 medical abortions.

At the time of inspection, there was a unit manager who had been in post since 1997 and was the registered manager.

A team consisting of one CQC inspector and one specialist carried out this inspection as part of our comprehensive inspection programme of termination of pregnancy services. As part of our inspection we reviewed medical termination of pregnancy services.

Overall inspection

Updated 21 October 2016

BPAS Amersham provided a compassionate, caring and non-judgemental service in line with BPAS values as an organisation. Sufficient staff were available with the skills and training to provide care. BPAS produced policies that took account of best practice policies and evidence based guidelines. For example, in line with Royal College of Obstetricians and Gynaecology (RCOG) guidance and the Required Standard Operating Procedures (RSOP) guidance from the Department of Health. BPAS also carried out its own research before the implementation of simultaneous early medical abortion up to nine weeks. Risk assessments and audits including how the service was adhering to legal requirements regarding completion and submission of HSA1 and HSA4 forms were undertaken. This information was reported monthly to head office as part of the organisation’s quality assurance processes. Incidents and complaints were reported, investigated and actions taken to reduce the recurrence. The unit manager had recently developed a unit risk register which was under review to monitor and mitigate risks. The service had received no formal complaints in 2015.

All staff were trained in safeguarding vulnerable adults and children (level 3) and obtained advice from the unit safeguarding lead or national safeguarding leads as needed.

Clear suitability for treatment guidelines were followed. In cases where women had complex medical needs, suitable alternative placements were identified to respond to their needs. All patients were offered a pregnancy options discussion with a client care coordinator as part of their consultation. The service signposted women to the 24 hours seven days a week after care advice line and post abortion specialist counselling if the need arose. Women were able to access services in a timely manner. Between April 2016 to June 2016, the proportion of patients in Buckinghamshire who had their consultation within seven days (five working days) was 69.7%. The percentage of available appointments was 98.5%.

However, staff who carried out point of care testing were not bare below the elbows or free of nail varnish in accordance with infection control policies.

Products such as blood test medium, pregnancy tests and condoms were stored on a trolley in a corridor which was accessible to members of the public and children.

The BPAS reception was a portable trolley located in the corridor outside the treatment rooms, this compromised patient dignity and confidentiality.