• Hospital
  • Independent hospital

BPAS - Bournemouth

Overall: Requires improvement read more about inspection ratings

23-25 Ophir Road, Bournemouth, Dorset, BH8 8LS 0345 730 4030

Provided and run by:
British Pregnancy Advisory Service

All Inspections

23 February 2023

During an inspection looking at part of the service

We carried out a focused follow-up on-site inspection on 23 February 2023 and had remote interviews with some of the management team on 2 March 2023.

We did not inspect all key questions as defined within our methodology. We focused on those areas highlighted in the Section 29 warning notice as requiring significant improvement. We also reviewed progress made where breaches of regulation were identified following our comprehensive inspection on 28 and 29 June 2022.

We did not change the ratings of the service as we focused on the areas previously identified in the warning notice and where breaches of regulation were identified.

The inspection was short notice announced to ensure the registered managers and documentation required to review would be available.

During our focused inspection we reviewed information to ensure the required actions against the Section 29 served against the provider in August 2022 had been completed. We found that:

  • Systems and processes to obtain two signatures on the HSA1 forms had improved.
  • The service was making progress against their action plan where breaches of regulation were identified.

28 June 2022

During a routine inspection

We previously inspected this service in 2016, however it was not rated at that time. This was the first time we rated this service. We rated it as requires improvement because:

  • The service did not always ensure the correct legal documentation was completed before surgical terminations.
  • The service did not always provide care and treatment following current national guidance to ensure pregnancy remains were treated with respect.
  • Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration. However, the service did not use a specific early warning system designed for children under the age of 16.
  • Systems to safely prescribe, administer and record medicines were not always in line with national regulations and guidance. However, medicines were stored safely.
  • The service provided mandatory training in key skills to all staff but not everyone had completed it.
  • The service mostly managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers mostly investigated incidents and shared lessons learned with the whole team and the wider service.
  • Waiting times from contact to consultation and treatment did not always meet standards in line with national standards and commissioning requirements.
  • Leaders did not always operate effective governance processes. However, staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.
  • Although leaders had the skills and abilities to run the service, they did not always have capacity to provide leadership as they had dual roles.
  • Not all staff understood the organisation’s vision and strategy, and they were not all aware of the freedom to speak up guardian and how to contact them.


  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use them. Staff managed clinical waste well.
  • The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix and gave bank staff a full induction.
  • Staff kept detailed records of patients’ care and treatment. Records were clear, up to date, stored securely and easily available to all staff providing care.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. They provided emotional support to patients, families and carers to minimise their distress. They understood patients' personal, cultural and religious needs.
  • The service planned and provided care in a way that met the needs of local people and the communities served. The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.
  • Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.

25 May 2016

During a routine inspection

BPAS Bournemouth 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 three formal complaints between January to December 2015 which had all been investigated and lessons learnt where appropriate.

All staff were trained in safeguarding vulnerable adults and safeguarding children to level 3) and obtained advice from the unit safeguarding lead or national safeguarding leads as needed. Arrangements were in place to transfer patients to the local NHS hospital if the need arose, accompanied by a member of BPAS staff.

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 BPAS client care coordinator as part of their consultation.The service signposted women to the after care advice line and post abortion specialist counselling if the need arose. Women were able to access services in a timely manner. In 2015 the proportion of women at BPAS Bournemouth who had their consultation within five days was 87%. The percentage of available appointments was 99.5%.

However, although the consultation documentation included a section on disposal of pregnancy remains,  our review of records showed that in four out of eight records the patients wishes with regards to disposal of pregnancy remains was not documented.

27 November 2013

During a routine inspection

The majority of patients were seen and treated under the NHS. If people were attending the clinic as a private patient the fees payable were clear and collected in accordance with the legislation in place.

People we spoke with on the day of inspection told us that they "were very happy with the care' 'staff were kind and non-judgemental'. The clinic's feedback questionnaires indicated that people were satisfied or very satisfied with the treatment and care received. People we spoke with felt that they had adequate information to make decisions and understood the risks associated with the options available.

Review of the care pathway for four patients and discussions with staff and people using the service evidenced that care was personalised and that people were supported by the clinic to make informed choices. There were appropriate arrangements in place to ensure the safety of people attending or working in the clinic. People who were vulnerable were safeguarded by the policies and procedures in place.

The building was well maintained and suitable for the service provided.

We were concerned about the arrangements for the cleaning the clinic. Cleaning facilities and equipment were not adequate for the service provided.

On the day of inspection there were adequate numbers of staff on duty in both the clinical and support service areas. Staff were appropriately qualified and trained for the roles they performed in the clinic.

31 July 2013

During an inspection looking at part of the service

During our inspection on 6 December 2012, we found that people were not made aware of the complaints system and it was not clear how people who wished to make a complaint would be supported to do so.

This inspection was undertaken to check that these concerns had been addressed. We found that the service had taken appropriate steps to ensure that people would be able to make complaints and be supported to do so.

6 December 2012

During a routine inspection

People we spoke with on the day of inspection told us that they "could not fault the service". Comments we observed in the feedback questionnaires indicated that people were satisfied or very satisfied with the treatment and care received. People we spoke with felt that they had adequate information to make decisions and understood the risks associated with the options available.

Review of records, discussions with staff and people using the service evidenced that care was personalised and that people were supported by the clinic to make informed choices. We reviewed the arrangements to manage emergencies and found that there were adequate arrangements in place to ensure the safety of people attending or working in the clinic.

We observed records for the maintenance of equipment and found that the equipment in the clinic was maintained. Daily and weekly checks were made by clinic staff and action taken if required.

Staff we spoke with felt supported by the British Pregnancy Advisory Service (bpas). They told us that they received training support and supervision. A new appraisal system for medical staff was in place and the doctor in the clinic said that "the medical care is safe and I feel well supported".

On the day of the inspection people did not have access to the bpas formal complaints procedure and it was not clear how people were supported to make a complaint. Feedback from people using the service on the day of the inspection was positive.

20 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 treatment for the termination of pregnancy was not commenced unless two certificated opinions from doctors had been obtained.