BPAS - Bournemouth

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

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

The evidence showed an exceptional standard. The service had a strong, proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

The organisation used the patient safety incident response framework (PSIRF) when responding to patient safety incidents. PSIRF is a national NHS initiative designed to improve how healthcare organisations in England respond to patient safety incidents.

In addition to this, the organisation had developed a patient safety incident response plan (PSIRP) which set out how BPAS intended to respond to patient safety incidents over a period of 12 to 18 months.

Leaders investigated incidents and shared lessons learned with the whole team and the wider service. Staff told us there were clear open and transparent processes for reporting and learning from incidents.

Staff also received a monthly newsletter which informed them of the number of incidents the organisation had seen that month along with complaints, concerns and feedback. The service kept a lessons learnt log which included what actions the service had taken and the learning that was shared.

Learning was shared via the sharing to ensure learning sessions (ShELS) which took place monthly and disseminated locally via initiatives such as ‘Safety Pins’ which were issued from the Patient Safety team. The purpose of the session was to ensure that any learning and/or improvements that have been identified and agreed were shared across the organisation.

Following a patient safety incident investigation at the Bournemouth site, the use of pre-filled saline flush was rolled out earlier than planned, improving the consistency across all sites at BPAS. This change in practice improved safety by eliminating manual filling and reducing the contamination risk.

The surgical team told us they attended a debrief post-surgery and discussed incidents, near misses, complications and suggestions for improvements.

After incidents and complaints relating to the disposal of fetal remains, the fetal remains policy was revised and process changes were implemented to ensure women were always aware of their choices with regards to this. Updates provided clearer guidance for staff, improved documentation, and enhanced communication with patients to ensure respectful and women centred care.

Telemedicine staff were supported to make sense of and learn from events, situations and actions of their work. Staff received reflective and clinical supervision as a core part of their clinical practice. The reflect & revise programme was introduced to implement a new format of call observation; to allow reflection and appropriate revision for telemedical service practitioners across BPAS, and to enhance collaborative and shared learning opportunities.

The service had reported no never events in the last 12 months. A "never event" is a serious, largely preventable patient safety incident that should not occur in a healthcare setting.

Staff told us they were encouraged and supported to raise concerns and felt they wouldn’t be treated negatively for reporting incidents or raising concerns.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service received referrals through the NHS. Patients could also self-refer by booking an appointment through the providers website.

A suitability assessment tool was used by clinicians to determine the type of abortion and anaesthesia suitable for each patient and confirm if they were suitable for treatment at the organisation or required referral into an NHS setting.

We reviewed 5 sets of patient records and saw that all HSA1 forms were completed in full and had signatures from two doctors. The HSA1 form is a legal document used in the UK to certify the grounds for an abortion under the Abortion Act 1967. It must be completed, signed, and dated by two registered medical practitioners before the termination of a pregnancy.

Patients who wished to use the pills by post service could contact the service to book an appointment. Following this, the patient received a telephone consultation and full medical assessment with a trained nurse or midwife who assessed their suitability for treatment. If treatment was found to be suitable and safe, patients received termination of pregnancy pills by post a few days later.

Based on the responses to specific questions during the telephone consultation, patients were invited for an ultrasound scan in order to determine precise gestation date of pregnancy prior to a medical termination. If gestation was greater than nine weeks and six days when the consultation took place, patients were offered a surgical termination in line with national guidance.

Additionally, all patients under the age of 16 received an routine ultrasound scan and face to face assessment. Staff could refer to the safeguarding team for advice and support.

Patients were taken to the recovery room post procedure and monitored until they were ready for discharge. To determine fitness for discharge, a final set of observations along with a number of wellbeing checks were carried out by a clinician. Patients who remained outside of discharge parameters were deemed unfit for discharge and remained in the unit to allow them more time to recover.

The providers website contained information about the different procedures offered and the risks associated with each. Patients could contact the aftercare line which was available 24 hours a day seven days a week if they had any concerns or required some advice and support.

Staff also offered patients to BPAS counselling services, for advice and support with their well being and mental health.

The service had an emergency transfer of patients to the local NHS hospital policy which set out the transfer agreement between the hospital and the clinic.

The evidence showed an exceptional standard. The service worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. They had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They always shared concerns quickly and appropriately.

Safeguarding at the organisation was led by a dedicated national safeguarding team. This consisted of a head of safeguarding and a named doctor for safeguarding who were trained to a level 5 alongside 7 safeguarding specialist midwives who were trained to safeguarding level 4 and DASH (Domestic Abuse Stalking and Harassment) train the trainer.

Staff at the unit and the telemedicine service received safeguarding training specific for their role. All staff were trained to a level 2 in safeguarding and, further to this, all clinical patient facing staff were trained to level 3. The service had rolled out anew safeguarding level 3 course, consisting of a 2 day training package. At the time of the inspection, approximately 50% of staff had completed this training, with the remaining staff booked to attend the course in November 2025. Post inspection we were provided with additional evidence which showed 100% completion rate for the clinic and 78% for the telemedicine hub.

All staff were trained to a level 2 in safeguarding and, further to this, all clinical patient facing staff were trained to a level 3 and are all DASH trained.

Level 1, 2 and 3 safeguarding training was delivered internally and covered key safeguarding topics pertinent to abortion care such as female genital mutilation, child sexual exploitation, mental health and mental capacity.

The organisation had an in date safeguarding children and adult policy. This provided staff with guidance on how to identify possible abuse and the processes to follow if they needed to raise a safeguarding concern.

Staff knew how to recognise, and report safeguarding issues and knew how to escalate safeguarding concerns if required. The organisation had a safeguarding lead who staff could contact for advice and support.

Additionally, the service had in place a chat function which staff at the clinic and the hub could use to access the safeguarding team should they have concerns about a patient.

Patients with safeguarding needs were discussed during the morning briefings ahead of the theatre list. This provided staff with a good overview of the patients as well as ongoing risks and involvement of social services.

The service provided staff with safeguarding supervision which involved regular, reflective conversations to discuss, reflect and learn from safeguarding cases. Staff could request this in a one to one, group, ad hoc or recommended format.

The service had made a total of 625 safeguarding referrals since April 2025 until September 2025 through their clinic and telemedicine hub. These were discussed at the monthly oversight meetings and learning from this was shared with all staff.

The service carried out a monthly audit for safeguarding under 18s and safeguarding adults. This included observations to check if staff had identified the presence or absence of safeguarding concerns and followed the under 18 responsible support person flowchart. Data provided by the service showed a 100% compliance score for safeguarding under 18s for the month of July, August and September 2025.

All patients under the age of 18 received a safeguarding risk assessment completed by a level 3 trained clinician. This comprehensive safeguarding risk assessment included asking about safety, relationships and past experiences. The service worked closely with social care, NHS, police and domestic abuse charities for support.

All women under the age of 18 using the telemedical service had part of their assessment conducted over a video call. This was to help staff assess if women were being coerced into having abortion treatment. Additional questions were included in the assessment process for young women to assess their sexual safety.

Leaders reported a positive reporting culture and all staff we spoke to were aware of the main risks and challenges and were able to discuss how they would safeguard individuals and the reporting process.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There were effective processes to ensure patients risks were assessed, monitored, and managed on a daily basis. Staff used a risk assessment tool which flagged up any follow up actions required throughout the patient pathway.

The service had a strict eligibility criteria for who could be safely treated at the clinic. Patients who did not meet the criteria were referred back to the NHS.

The surgical team conducted briefings prior to the surgical treatment to agree on the plan for the day and ensure safety and risk was managed and monitored. We followed a patient journey on the day of the inspection and saw evidence of positive patient identification in the preoperative assessment; the anaesthetics room and the treatment room. We also saw evidence of the world health organisation (WHO) checklist and staff counting the instruments and swabs on trolley.

Patients who had a surgical termination were risk assessed. All patients were risk assessed for deep vein thrombosis using an appropriate tool. Additional information about allergies to medicines was obtained as part of the surgical safety check list. We reviewed 5 patient records and found these to be complete.

Every young person under 16 received a face to face consultation and was risk assessed to ensure their safety. Whilst young people aged 16-18 also received the same risk assessment, they had the option of a virtual video consultation to receive this as well as the face to face option. The risk assessment was based on the national tool ‘Spotting the Signs’ and took into consideration laws around consent whilst balancing the provision of advice and treatment for contraception, sexual and reproductive health.

Staff were aware of specific national guidance and legislation relating to the termination of pregnancy according to the gestational age (the time from conception based on menstrual cycle). Individual risk assessments were completed for all patients who attended the clinic or through telephone consultations. There were specific eligibility criteria to assess if patients were safe to receive a medical abortion in their own home or a surgical termination at the clinic.

Staff shared key information to keep patients safe when handing over their care to others. Staff held a safety briefings each morning when surgical terminations were carried out. During the safety briefing, staff were made aware of specific patient risks or needs. Each member of staff was assigned a role in the event of a clinical emergency, including the transfer of a patient to an NHS hospital. We observed a safety briefing during our onsite visit and found information was clearly shared and all staff were engaged with the safety briefing.

Staff shared and referred patients to counselling services if required. When patients were discharged, staff ensured they knew they could access the BPAS counselling at any point in the future if this was required, with concerns or issues relating to the termination of their pregnancy.

The organisation had an admission and discharge in the surgical pathway policy which was due for review in March 2027. The policy was accessible to all staff and set out the key steps to ensure admission and discharge process was carried out in a safe and effective manner.

The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment.

The clinic carried out environmental risk assessments. The level of risk was identified by a colour code system of red, amber, green and purple (RAG) level. A recent fire risk assessment of the clinic which was carried out by an external company in January 2025 had identified four areas which required immediate action. A review of the action tracker showed only two of these to be complete with no target date of completion for the other two areas.

Additionally the clinic had also used an external company to carry out a health and safety compliance audit in January 2025. The results of this highlighted seven areas where further action was required to improve safety management with an agreed timescale to complete this. A review of the action tracker showed that the actions for six out of the seven areas had been completed.

The clinic was located within a residential area with on-street parking for patients. There was restricted access to the building and CCTV monitoring of outside areas to deter people who had no right to access or enter the premises.

We found the environment to be clean and safely arranged with secure access to clinical areas and areas within the clinic.

Facilities and equipment were well maintained and we found all equipment to be PAT (portable appliance testing) tested and in date.

Staff had access to emergency equipment and we found these to be checked regularly and up to date.

The waiting rooms within each area of the clinic had plenty of chairs for patients to sit on with access to leaflets about the treatment and procedure.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff within the clinic and the telemedicine services received clinical and safeguarding supervisions. We reviewed the operational compliance dashboard for the clinic which showed the target for clinical supervision had not been met since February 2025 until September 2025 due to staff sickness. Likewise, data for the telemedicine hub showed the safeguarding supervision target not being met for the month of August and September 2025 for the same reason. At the time of the inspection, the telemedicine hub had a plan to book the last attendance in January 2026 which would make them fully compliant. Likewise the clinic were making good progress against their clinical supervision compliance and scored 90% for the month of September 2025. Both units had action plans to manage this and kept track of progress through their compliance dashboard.

Staff completed mandatory training via e-learning and face to face sessions These included mental capacity act and safeguarding. Additional data provided by the service showed overall compliance for mandatory training at 92.8% for the clinic and 94.6% for the telemedicine hub.

Staff we spoke with told us they received appraisals. A review of the data provided by the service showed all telemedicine services staff had received an appraisal. This was also the case for all staff working at the clinic with the exception of one member of staff who was out of the business.

The service had enough nursing and medical staff to keep patients safe and completed regular reviews to ensure staffing levels could meet demand. At the time of the inspection, the service reported no vacancies.

When necessary, the service deployed agency and bank nursing staff to maintain safe staffing levels. The service reported the total usage of 1.84% from October 2024 until September 2025 for the telemedicine hub service. This was 1.67% for the clinic.

New starters received an induction and supernumerary for 12 weeks before they followed a pathway for patients to get an overview of the service and ensured competencies were met.

The service employed five consultant anaesthetists and a surgeon under practising privileges (a 'licence' agreed between individual medical professionals and a private healthcare provider) to facilitate general anaesthetics for patients who were booked for surgical terminations at a later gestation stage or if that was the patient preference.

There were processes for the granting and reviewing of practising privileges arrangements annually which included an interview, an induction for consultants and a review of their appraisal documentation.

The clinic reported high sickness rates, for the month of July, August and September 2025, these were 12.07%, 6.68% and 8.38% respectively. Staff sickness was also one of the risks on the clinic’s risk register and the service was mitigating this by utilising bank staff where possible and monitoring staffing levels to ensure patients received safe care.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

All areas within the service were visibly clean, clutter free and well maintained. Cleaning records were up to date and demonstrated that the areas within the service were cleaned regularly.

There were adequate hand washing facilities within the service. Staff adhered to infection control principles, including handwashing and had access to PPE (personal protection equipment). We observed staff were bare below their elbows and washed their hands prior to and following contact with patients.

The service had in house laundry facilities on site where uniforms and curtains were washed. All curtains in the recovery rooms were made of fabric and changed every 3 months or more regularly if required. Staff told us they cleaned the curtains if these were soiled with blood or other bodily fluids more regularly.

The service completed monthly audits for hand hygiene and uniform audits as part of the annual infection, prevention and control audits. Data provided by the service showed a compliance of 100% for the hand hygiene audit and 95% for the uniform score for the month of September 2025. Following this the service had an action plan to achieve 100% compliance with uniform which included ensuring the team are aware of the standards required.

In addition to this, the service also completed monthly cleaning audits for the surgical unit as per the national standards of cleanliness guidance. We reviewed this for the month of September and August 2025 which showed compliance as 100%.

The service reported 0 cases of healthcare acquired infections in the 12 months before the inspection.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

Staff stored and managed all medicines and prescribing documents safely. Medicines, including controlled drugs (CD) and medical gases cylinders, were stored securely.

We also checked the CD logbook and found it to be completed correctly. The service carried out monthly medicine management audits which included Patient Group Directions (PGD), CD and medicines reconciliation. Post inspection provided showed a total overall compliance of 82% for these audits.

The keys to the medicine fridge were kept in a lockable cupboard. Staff kept a file with checklists for monitoring the fridge temperature, cleaning schedules and emergency bell testing. We checked the fridge temperature in theatre and anaesthetics and founds these to be within range. Sharp boxes were clearly labelled and dated.

Medicines as ‘to take out’ (TTO) packs were issued by nursing staff either against PGDs or against a prescription from a prescriber. PGDs are written instructions which allow specified healthcare professionals to supply or administer certain medicines in the absence of a written prescription.

Staff provided advice to patients about their medicines. Staff reviewed patient’s medicines regularly and provided specific advice to patients and their next of kin about their medicines. For patients using the pills by post service, there was information on the providers website about the expected effects of treatment and the risks and complications associated with the abortion pill.

The organisation produced a medicine safety report which provided the organisation’s quality and risk group, and also the local integrated care board (ICB), with a comprehensive overview of medication safety within the organisation.

The drugs and therapeutics committee also sat under the quality and risk group and met quarterly as a team to discuss patient group directions and protocols and medicine formulary update.