The Care Quality Commission
  • Hospital
  • Independent hospital

BPAS - Doncaster

Overall: Requires improvement read more about inspection ratings

Danum Lodge Clinic, 123 Thorne Road, Doncaster, South Yorkshire, DN2 5BQ 0345 730 4030

Provided and run by:
British Pregnancy Advisory Service

All Inspections

20 April 2022

During a routine inspection

Our rating of this location improved. We rated it as requires improvement because:

  • The service had suitable premises and equipment. There were enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The service provided mandatory training in key skills to all staff and made sure everyone completed it. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • Staff kept detailed records of patients’ care and treatment and followed BPAS processes when prescribing, administering, recording and storing medicines. Staff completed and updated risk assessments for patients undergoing surgical and late medical terminations of pregnancy. The service reported and managed patient safety incidents well.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Staff assessed and monitored patients regularly to see if they were in pain. Staff followed appropriate consent processes. Staff supported patients to make informed decisions about their care and treatment. Staff promoted sexual health in line with national guidance. There was an emergency transfer agreement with the nearest acute hospital.
  • Staff cared for patients with compassion and provided emotional support to patients. Staff involved patients’ decisions about their care and treatment.
  • The service managed and investigated concerns and complaints appropriately. The service coordinated care with other services and providers.
  • The service had a vision for what it wanted to achieve and workable plans to turn it into action. Managers promoted a positive culture that supported and valued staff. There was inclusive and effective leadership at all levels. Leaders demonstrated the experience, capacity and capability needed to deliver sustainable care.
  • Staff throughout the service were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities, were proud of the organisation as a place to work and spoke highly of the culture. Staff were actively encouraged to speak up and raise concerns.

However, we found the following areas where the service could improve:

  • Staff could not articulate how to assess risk of deterioration in children and there were no supplies of emergency equipment suitable for intubation of children.
  • There was no thermometer to monitor the temperature of the nurses’ office where the to take out (TTO) medicine cupboard was located. This could impact on the stability of the medicines stored within this area.
  • People could not access the service when they needed it to receive the right care promptly. Although waiting times had improved, these were not in line with national standards.
  • Although leaders had begun to operate effective governance processes throughout the service and used systems to manage performance effectively, these were new processes and had not had time to become embedded in practice or show consistent improvements.

04/08/2021

During an inspection looking at part of the service

This was a focused, unannounced inspection in response to specific areas of concern. We rated this service inadequate overall because:

  • The service did not always operate effective safeguarding processes and systems to protect people from abuse
  • Staff did not always identify nor quickly act upon patients at risk of deterioration following a surgical procedure. Though staff completed risk assessments these were not comprehensive, nor did they remove or minimise all key risks
  • Though staff kept records of patients care and treatment these were not always fully completed, clear or up to date
  • The service did not operate effective systems and processes to safely prescribe, administer, record and store medicines
  • Staff did not always recognise and report incidents and near misses
  • The service did not always provide care and treatment based on national guidance and evidence-based practice. Managers did not consistently check to make sure staff followed guidance
  • Staff did not always support patients to make informed decisions about their care and treatment. They did not consistently follow national guidance to gain patients’ consent. Staff did not recognise, assess, or record a patient’s possible lack of mental capacity to make decisions
  • The service did not always coordinate care with other services and providers
  • Leaders and managers did not always understand and manage the priorities and issues the service faced
  • Leaders did not operate effective governance processes throughout the service. They did not use systems to manage performance effectively. They did not always identify and escalate relevant risks and issues nor take action to reduce their impact

However:

  • The service provided mandatory training in key skills to all staff and had processes in place to make sure everyone completed it
  • 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
  • All those responsible for delivering care worked together as a team to benefit patients. They supported each other to provide good care and communicated effectively with each other
  • The service was inclusive and took account of patient’s individual needs and preferences. Staff made reasonable adjustments to help patients access services
  • Leaders were visible and approachable in the service for patients and staff
  • Staff felt respected, supported, and valued. They were focused on the needs of patients receiving care. The service had an open culture where staff could raise concerns without fear.

Following this inspection, under Section 31 of the Health and Social Care Act 2008, we served an urgent notice of decision to impose conditions on the location’s registration as a service provider in respect of regulated activities. We took this urgent action as we believed a person would or may be exposed to the risk of harm if we had not done so.

The provider responded giving assurance of their intention to review systems and processes to minimise risk. The corporate provider responded with an action plan; however, we were not assured of the timeliness of some of the actions to address immediate risk.

We served a further urgent letter of intent on 18 August 2021 to require the service to review and investigate incidents where service users had been transferred to the local NHS service.

We received assurance from the provider that they had taken action to address the risks and we did not take any further enforcement action.

This service has been placed into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

23 to 24 October 2019

During a routine inspection

We rated it as Good overall.

We found the following areas of good practice:

The service had suitable premises and equipment. There were enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The service provided mandatory training in key skills to all staff and made sure everyone completed it. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

Staff kept detailed records of patients’ care and treatment and followed BPAS processes when prescribing, giving, recording and storing medicines. Staff completed and updated risk assessments for patients undergoing surgical and late medical terminations of pregnancy. The service reported and managed patient safety incidents well.

The service provided care and treatment based on national guidance and evidence of its effectiveness. Staff assessed and monitored patients regularly to see if they were in pain. Staff followed appropriate consent processes. Staff promoted sexual health in line with national guidance. There was an emergency transfer agreement with the nearest acute hospital.

Staff cared for patients with compassion and provided emotional support to patients. Staff involved patients’ decisions about their care and treatment.

The service managed and investigated concerns and complaints appropriately.

The service had a vision for what it wanted to achieve and workable plans to turn it into action. Managers promoted a positive culture that supported and valued staff. There was inclusive and effective leadership at all levels. Leaders demonstrated the experience, capacity and capability needed to deliver sustainable care.

Staff throughout the service were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities, were proud of the organisation as a place to work and spoke highly of the culture. Staff were actively encouraged to speak up and raise concerns.

However:

Some patients waited longer than two weeks from first contact to treatment which was outside of Required Standard Operating Procedures (RSOP) as specified by the Department of Health. Some national and local actions had been put into place to reduce this. However, audit results continued to show missed targets.

Although we observed good medicines management and practice throughout our inspection, audit results showed the service had failed to meet BPAS requirements for medicines management on six occasions.

Two trolley mattresses were found to be torn. It was not clear if one of these was the same trolley mattress identified in an internal infection control audit in December 2018. Therefore, it was not clear if the service acted upon identified infection control risks.

The service did not use a paediatric specific early warning score for young patients and, in the case of a young patient who developed sepsis, a modified early warning score (MEWS) was not used on admission.

Although staff told us they were committed to improving services continually, audit results did not show lasting improvements on dashboards although actions were identified and managed to ensure positive changes.

Following this inspection, we told the provider that it must make some improvements, because a regulation had been breached, and to help the service improve. Details are at the end of the report.

16-17 November and 2 December 2015

During an inspection looking at part of the service

Termination of pregnancy services caring, effective, responsive and well led; however, there were some areas for improvement in the safe domain.

There was a culture of reporting and learning from incidents, across the organisation and within the Doncaster service. Staff could demonstrate their understanding of safeguarding adults and children and knew what actions they needed to take in cases of suspected abuse. All patients received a private initial consultation without anyone else present to safeguard against possible coercion or abuse and to give them the opportunity to disclose such information in a safe environment. Staffing levels, medicine management and record keeping were good.

However, we found that the theatre environment was not properly clean during our first visit; but this had been resolved when we carried out our unannounced inspection Staff did not always wear aprons when delivering personal care in clinic areas. There were trip and injury hazards in the theatre and recovery area due to lack of space. Surgical safety checklists / briefings were not always effective. It was not clear from records if all appropriate water outlets were flushed following closure of the unit on non-working days. There was a lack of assurance whether the ventilation in theatre and the pack room met the required standard

Staff followed evidence-based guidelines, patient assessments were thorough and staff followed clear pathways of care. The service managers used a clinical dashboard, which measured and facilitated improvement in the quality and safety of clinical standards. Staff were competent and observation and assessment of staff competence was an integral part of pathway audit.

Staff treated patients with compassion, dignity, and respect. They focused on the needs of each patient and responded quickly to their needs. Staff were very aware of the additional needs and risks associated with the care of young people and made every effort to ensure young people were supported through their treatment. Patients gave very positive feedback in the BPAS Patient Satisfaction reports.

Waiting times were consistently within the guidelines set by the Department of Health, unless patients chose appointment times outside the recommended timescale. Information and advice were available from staff, leaflets and on-line to women at all stages of their care. Interpreting and counselling services were available to all patients and staff made every effort to meet individual patients’ needs. Staff had access to a specialist placement team who would arrange referral to appropriate providers for patients with complex or additional medical needs, who did not meet usual acceptance criteria. There were systems in place to ensure sensitive disposal of foetal remains.

The organisation had a clear mission to provide for safe and effective care. Senior managers had a clear vision and strategy for this service and there was strong local leadership of the service with quality care and patient experience seen as the responsibility of all staff. Staff felt supported by their managers and were confident they could raise concerns and have them dealt with appropriately. There were effective governance systems in place and staff received feedback from governance and quality committees. There were corporate risk registers and business continuity plans in place. Local risks were identified separately in general risk assessments. Some of the local risk assessments were due or overdue for review. Department of Health requirements were met. The organisation had a proactive approach to staff and public engagement. Innovation, learning, and development were encouraged.

22 October 2013

During a routine inspection

During our inspection we spoke with two people who used the service, observed the consultation process and discharge procedure following treatment.

Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. We saw that risks, complications and alternative treatment options were discussed and explained to people before they gave consent to treatment. Staff were aware of the consent procedures for children under 16. They had a good understanding of assessing whether the young person had the maturity to make their own decisions and to understand the implications of those decisions.

People experienced care, treatment and support that met their needs and protected their rights. People had detailed care and treatment plans relating to all aspects of their care needs. People we spoke with were positive about the service. One person said, "Care was good, staff were kind and treated me well." We also looked at a sample of feedback forms. The comments included, "Excellent service" "Care and stay fantastic" and "Great, welcoming and supportive."

People were cared for in a clean, hygienic environment. There were effective systems in place to reduce the risk and spread of infection. People we spoke with had no concerns with the cleanliness of the service.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. Medicines were prescribed and given to people appropriately.

People were cared for, or supported by, suitably qualified, skilled and experienced staff. Appropriate checks had been undertaken before staff started work. This included being registered with the relevant professional bodies.

There was an effective complaints system available. Comments and complaints people made were responded to appropriately.

18 December 2012

During a routine inspection

We found arrangements were in place so people's privacy and dignity was maintained. People told us they had been treated respectfully and their confidentiality had been maintained.

People who used the service understood the care and treatment choices available to them. Staff told us people were given a period of time between their consultation and treatment. This enabled them time to consider all of the information they had been given, before deciding whether to go ahead with the treatment or not.

People who used the service experienced care, treatment and support that met their needs and protected their rights. They had detailed care plans relating to their care needs. People were very positive about the service. One person said, "The care has been excellent."

People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Staff we spoke with were aware of safeguarding policies and procedures.

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. The staff we spoke with demonstrated a good knowledge of the people they supported.

The provider had an effective system to regularly assess and monitor the quality of service that people received. There was evidence that learning from incidents and investigations took place and appropriate changes implemented.

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 no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.