BPAS - Bournemouth

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We have not awarded this service a score for Well-led.

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

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The organisations vision was to be the leading provider of equitable, high-quality sexual reproductive healthcare, integrating digital innovation and research driven practices.

The organisation had a strategy for 2025-28 which had been developed with involvement of over 600 staff via workshops and engagement sessions. The strategy included six strategic objectives, one of this included streamlining abortion and reproductive healthcare services to improve patient access and delivering better patient centred care.

Engagement with staff was via meetings, emails and newsletters. The service held feedback forums and workshops for staff in order to improve communication and build a more supportive and inclusive culture.

There was a transparent and open culture where staff could escalate concerns and report incidents. Staff reported that the team was supportive and were excellent at updating staff on changes and developments of the service.

Staff spoke passionately about the service they provided and were proud of the facilities they worked in and the care they could offer to patients. Staff described the culture as positive with good working relationship.

We observed positive and caring interactions between staff and their patients and their relatives who used the service. We also noted good collaboration and communication between staff of all grades and disciplines.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders within the service had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced and could explain clearly how the teams were working to provide high quality care.

All staff reported that senior managers are visible, approachable and they felt confident they could approach them about anything. Staff felt supported by leaders to develop their skills and take on more senior roles.

Staff told us the communication systems and team working within the service were effective. A staff member told us ‘Everyone works well together; leaders are excellent at updating us on changes and updates of the service.’

To comply with their practicing privileges agreements, all doctors working for the organisation were required to provide up to date and accurate documentation on an annual or biannual basis. The organisation kept a standard operating procedure which detailed the processes for obtaining this information and for escalation of cases where required documentation was not forthcoming.

The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service encouraged a positive culture where everyone felt empowered to voice their concerns, knowing their input will be heard and acted upon.

Staff had access to a freedom to speak up guardian who was available should staff wanted to raise any concerns. Staff were aware of who this was and told us that they felt they could raise concerns without fear of reprisal.

The freedom to speak up guardian maintained a log of all concerns raised under the freedom to speak up procedure and highlighted areas of risk or remedial action as required.

Staff could also access the organisation speaking up policy which provided information on how to speak up and what to expect to happen after speaking up. All senior leaders across the organisation were responsible for the implementation of this policy and are ambassadors for supporting and creating a culture of openness and transparency in which all workers felt safe to speak up.

We reviewed the people survey 2024 for the telemedicine services which showed an improvement in all survey areas when compared to the previous year. This included staff feeling comfortable raising and reporting any concerns to a senior manager.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service valued diversity in their workforce. Staff worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The organisation had an equality, diversity, inclusion and belonging plan for 2025/26 which aimed to create an environment where every individual felt a sense of belonging, where diversity was celebrated and where opportunities to thrive was accessible to all. One of the main elements within the plan was to provide a comprehensive training for hiring managers on inclusive recruitment best practices, ensuring they represent the organisation positively and minimise the risk of discrimination.

The organisation was committed to ensuring that equality and diversity was a fundamental principle in all policies and procedures within the trust and these were effectively promoted and used equitably across the organisation. The yearly people survey looked at different reporting themes one of which included equality, diversity, inclusion and belonging. We reviewed the people survey for the clinical services and the telemedicine hub services for the service for 2024 which showed an improvement in both areas.

Staff received equality and diversity training as part of their mandatory training. At the time of the inspection 93.1% of clinical staff and 97.7% of the telemedicine hub services staff had completed this training.

The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service was last inspected in February 2023 to follow up on areas which were previously identified in a section 29 warning notice. The inspection had found that the service had made improvements on areas where breaches had been identified and were making progress against their action plan. At this inspection we found the majority of these improvements had been embedded and sustained throughout the service.

Managers monitored activity and wait times for all surgical lists through a variety of processes, including operational key performance indicators and a monthly overview of patient safety activity using a dashboard approach.

The clinic reported surgeon cover disruptions for 5 planned surgical lists during the months of April, August and September 2025. The service was aware of the national shortage of specialist surgeons and had mitigations to manage this, which included managing the surgeon cover nationally to ensure maximum lists were covered and additional lists planned during the weekend or on alternative days to minimise wait times.

There was a clearly defined structure to the service for the clinic and telemedicine hub. Both areas were led by a treatment unit manager and a clinical lead. The clinical services team and the telemedicine hub team met monthly and topics of discussion included activity reports, staffing, clinical supervision and complaints.

The organisation continued to monitor effectiveness through the local clinical audit compliance board (LCACB) which was a programme of audits undertaken by each treatment unit (dependant on the service provided) and telemedicine hub. We found full discussion and analysis of the results within the clinical governance meeting minutes.

Leaders for both services also met monthly to discuss audits, performance, safeguarding and competency assessments. Information discussed within these meetings was shared with all staff. Staff told us information was also shared between different clinics where learning had been identified.

Staff at all levels were clear about their roles and understood what they were accountable for, and to whom. There were clear responsibilities among staff which interconnected and ensured governance was fundamentally strong.

The clinical services team and the telemedicine hub team kept their own risk registers. We reviewed the risk register for both services. The top risk for the clinic was limited surgeons within the organisation which led to challenges with arranging surgeon cover for absences which could impact on the wait times for surgical treatment. Staff access to the premises and security was rated the highest for the telemedicine hub services.

Risks were reviewed and progress against them and the mitigations monitored through 6 committees who reported directly to the quality and risk group. Additionally there were two groups/meetings which were also accountable to the quality and risk group and these were the event response group (semi-weekly) and the national integrated performance meetings (monthly). We reviewed the integrated performance reports for the months of July 2025 to September 2025 and found evidence of discussions of risks held by the service and the mitigations and progress update for each risk. Divisional risks were also shared with the staff via the monthly newsletter along with incidents and general updates.

There were processes for the granting and reviewing of practising privileges arrangements annually. The organisation had a standard operating procedure (SOP) in place for doctors with practicing privileges. This SOP covered record keeping requirements, escalating process and the duties of the responsible officer advisory group and outlined the processes for obtaining required information from practicing privileges doctors and escalation of non-compliance.

The service consistently operated systems to ensure they shared information with external organisations effectively, in a timely way, for example, accidents and incidents were reported to the relevant authorities, including the CQC.

There were procedures to safely manage sensitive data which allowed them to maintain people’s privacy, dignity and confidentiality. Governance meeting minutes we reviewed showed staff from different areas of the service attended and were involved in discussion about the service and how improvements could be made.

The service had a local business continuity plan in place to ensure the service was able to continue to deliver essential patient care and associated services in the face of a disruptive incident. The plan included the initial actions which had to take place and the staff roles in the event of an incident.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service collaborated and worked in partnership with stakeholders to support the delivery of the service and support joined up care. They shared information and learning with partners to improve the service.

The organisation had well-established relationships with a wide range of stakeholders including the local integrated care board, primary and secondary care. They were members of the pan provider network which included the NHS and other independent providers within Dorset to collaborate on the pathway.

The clinic and the hub worked closely with a number of services nationally, some of which included the police, social services and the local early pregnancy assessment services. There was an established process that enabled team members to access appropriate referral information for cases such as continuing pregnancies or patients requiring support beyond the termination of pregnancy pathway, including mental health, safeguarding, and GP pathways.

The service also worked in partnership with their local acute hospital and shared information and learning with them to ensure smooth transfers in emergencies/non emergencies.

Staff were also able to access the child protection information sharing system which enabled them to share information with partners in order to better protect vulnerable children.

The Bournemouth service was part of the southwest triumvirate group along with other services within the southwest of England. The group met monthly to discuss operational performance, finances, risks and research and innovation.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The service used information through incidents, complaints and feedback from patients and reviewed this through governance meetings to improve the safety and quality of service for patients.

The service provided us of the projects that had been undertaken by the patient experience team so far this year, one of which included the recruitment of patient representatives and launching a staff magazine where patient stories would be shared with the team.

The service was also in the process of creating a survey for patients with learning disabilities via an easy read paper format and setting up satisfaction kiosks in the clinic.

Additionally the service provided us with the organisations research and innovation project register which included the list of active research projects with an overview and timeline.