BPAS - Bournemouth

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated effective as requires improvement. At this assessment the rating has changed to good.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff effectively communicated with patients to meet their needs. For example, we observed a member of staff supporting a patient who was anxious about a treatment and staff interacted with them in a calm manner and helped them relax.

While not using a single standardized scale, the organisation conducted research and explored tools like the behavioral pain scales (BPS) and direct patient feedback to understand pain better and develop better pain relief strategies for a more comfortable patient experience.

Staff discussed patients’ needs with them, and they were involved in how care and treatment was planned. We observed a discharge process following a surgical procedure where staff provided the patient with information and counselling about contraception.

We looked at five patient records which demonstrated full assessment and consideration of patient needs from initial contact through to the different pathway. Risks had been considered and documented including VTE (Venous Thromboembolism) and gestation period.

In addition to this, information was shared with patients about their options for termination and handling of pregnancy remains.

Staff told us they could place flags on their system for patients with additional needs for example with a safeguarding issue. This alerted staff later in the patients’ journey.

The service facilitated safety briefings which provided staff with a good overview of the needs of the patients who had been booked for a procedure on the day. We observed a morning safety briefing where information relating to safeguarding concerns, dietary requirements and any risks or special needs associated to the patients were communicated to the team.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Effectiveness of care and treatment was measured through various methods including local and national audits, wait time data and through incident reports.

The organisation continued to monitor effectiveness through the local clinical audit compliance board (LCACB). This was a programme of audits undertaken by each treatment service (dependant on the service provided) and telemedicine hub. These included infection prevention and control audits and surgical notes audit. These were completed monthly, annually and at an ad hoc frequency. Where compliance was not 100%, the service implemented action plans to rectify this. The service had oversight of this through their local clinical audit compliance board and an action tracker which included issues identified and what actions were required with a completion date.

The telemedicine hub carried out the same monthly audits within the LCACB programme which included safeguarding adults and under 18, consultation notes and consent. We reviewed the audit for consultation and consent for the month of September 2025 which reported an overall compliance of 99%.

Additionally, the service also audited their calls within the booking information centre and aftercare departments for quality reassurance and standardisation.

Staff participated in peer reviews and had access to the reflect and revise policy which allowed self-reflection and revision, and peer to peer shared learning.

The service used audits to benchmark themselves with other locations within the organisation to improve patient care and treatment. The organisation kept an operations compliance dashboard which provided an overview of the operational key performance indicators (KPI) for the individual services throughout the organisation. Leaders told us this allowed key individuals to discuss where areas of improvement were needed and highlighted good practice where continuous improvement was sustained.

The service had a ‘pregnancy remains: dignity and disposal’ policy which was based on the Human Tissue Authority (HTA) guidelines. There were 4 pathways and the service used 2 disposal logs to document how the pregnancy remains were collected. Leaders told us monitoring compliance with this policy was through the audit of case notes and pregnancy remain/sensitive disposal logs through the local clinical audit compliance board programme.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff within the unit and telemedicine hub met monthly to discuss training, performance management and wait times etc. The leads for the unit and the telemedicine hub also met monthly to discuss audit results, succession planning and rota cover.

The surgical team held a briefing prior to the commencement of a surgical list. We observed a briefing where information about patients was shared with all staff present. Patients with additional needs or known risks were highlighted to the staff to ensure they were supported and looked after.

In addition to this the service also held internal strategy multidisciplinary meetings to discuss patients who required additional support or required additional planning to facilitate treatment.

Staff told us they liked the variety of working across the service and described good patient continuity with usually permanent staff working.

The service provided an example of how the clinical team had worked together to support a patient who had disclosed safeguarding concerns. By working together as a team and liaising with the local safeguarding team and the police, staff were able to support the patient throughout their pathway which ensured they received the appropriate treatment and care.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Patient records showed risks had been considered, discussed and documented. Staff also provided patients with advice on contraception.

The organisations website contained a wealth of information regarding contraception and sexually transmitted infections (STI). Staff recommended patients for routine STI testing as infections left untreated could become painful or cause long-term health problems.

Patients could access information on other services like the national sexual health helpline through the providers website.

Additionally, the clinic maintained relationships with the drug and alcohol agencies and liaised with them to ensure understanding of patient needs, and how best patients can be supported through treatment and aftercare.

Staff offered refreshments to patients who attended for surgical termination of pregnancy. All patients were offered drinks and snacks following their surgical procedure as part of the post-procedure recovery. There were adjustments for patients with specific allergies or preferences.

The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service monitored outcomes of treatment in line with national guidance. These included patient satisfaction feedback, complaints, complications, incidents and safeguarding referrals.

The Bournemouth clinic was part of the southwest division in BPAS and produced a monthly integrated performance report, which had a specific focus on activity, outcomes and processes. There were also agreed targets to be met with clinical commissioning groups and regular review meetings to discuss performance.

In addition to this, the service also took part in multiple national and local clinical audits. There were processes to monitor audit results and make improvements. These included a monthly audit of BPAS compliance with HSA1 rules and regulations and the biannual audit of BPAS surgical notes. The service provided us with the HSA1 compliance audit data for the clinic from April 2025 until June 2025. Results showed all standards set were met and no breaches were identified.

Women’s access to their preferred choice of contraception when they have an abortion was measured in accordance with the NICE abortion care quality standards. Improving access to contraception reduces the risk of future unintended pregnancies and abortions and has a positive impact on women’s experience of care. Following an improvement program which involved cascading additional training around contraception, the organisation had seen an improvement in the uptake of contraception from 26.9% in 2023/24 to 35.8% in 2024/25.

The service made sure that people could access the care, support and treatment they needed when they needed it.

The service completed monthly consent audits for the clinic and telemedicine hub. Data provided to us post inspection showed compliance scores to be 99% for September and August and 98% for July 2025. Following this the service had implemented an action plan to improve compliance to 100% by reminding everyone to offer email consent. This was communicated via weekly bulletins and by noting it in the quality improvement board.

The electronic patient care record included checks and evidence that authorisation from two medical clinicians had been obtained before any medical or surgical terminations of pregnancy was provided. We looked at 5 patient records and found these to be completed.

Staff took all practical steps to enable patients to make their own decisions. Consent was sought from patients prior to the procedure. We observed staff asking for consent prior to undertaking a procedure.

Staff understood Gillick Competence and Fraser Guidelines and supported children who wished to make decisions about their treatment. Gillick Competency and Fraser Guidelines are legal judgements that set out the ‘rules’ around when a child is deemed to be competent to make their own decisions. All patients under the age of 18 years of age were required to attend the clinic with a responsible adult. If the patient did not have an adult that could escort them, the care team would work with the patient and receive peer support from the safeguarding team to identify an appropriate alternative.

Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Health Act, Mental Capacity Act 2005 and the Children Acts 1989 and 2004 and they knew who to contact for advice.

Staff could describe and knew how to access policy and get accurate advice on Mental Capacity Act and Deprivation of Liberty Safeguards.