The Care Quality Commission
  • Hospital
  • Independent hospital

BPAS - Merseyside

Overall: Requires improvement read more about inspection ratings

32 Parkfield Road, Liverpool, Merseyside, L17 8UJ 0345 730 4030

Provided and run by:
British Pregnancy Advisory Service

All Inspections

25, 26 and 31 May 2022

During a routine inspection

This was a comprehensive, unannounced inspection to follow up on enforcement action taken during an inspection in August 2021 where we identified specific areas of concern.

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

  • The service did not have a system for the observation of children under the age of 18 years using the modified early warning score (MEWS) to ensure early recognition and safe timely escalation of a deteriorating children.
  • Staff did not always give an effective handover, which included all relevant information, when women moved between different stages of their treatment.
  • Women did not always receive treatment within agreed timeframes and national targets.
  • Not all staff felt respected, supported and valued.
  • Though improvements had been made since our last inspection the service had not had sufficient time to show improvement was embedded and could be sustained.

However:

  • The service had improved its processes and systems to safeguard people from abuse and manage patient safety incidents. Staff now comprehensively assessed and documented risk assessments.
  • The service had enough staff to care for women and keep them safe. Staff had training in key skills, understood how to protect women from abuse, and managed safety well. The service controlled infection risk well. The service managed medicines well.
  • Staff provided good care and treatment and gave women pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of women, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Staff followed national guidance to gain women’s consent, this was an improvement from our last inspection.
  • Staff consistently treated women with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to women, families and carers.
  • The service planned care to meet the needs of local people, took account of women’s individual needs, and made it easy for people to give feedback. People could access the service when they needed it.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. They were focused on the needs of women receiving care. Staff were clear about their roles and accountabilities. The service engaged well with women and local services to plan and manage services and all staff were committed to improving services continually.

04 August 2021

During an inspection looking at part of the service

This was a focused, unannounced inspection in response to specific areas of concern. Our rating of this location went down. We rated it as inadequate 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 removed or minimised every key risk.
  • 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. Managers did not always investigate incidents.
  • Managers did not consistently check to make sure staff followed national and local 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 made sure everyone completed it. Staff received training on how to recognise and report abuse.
  • 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.
  • When managers investigated incidents, they shared lessons learnt with the whole team and across BPAS.
  • The service provided care and treatment based on national guidance and evidence-based practice.
  • 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 patients’ 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 immediate risk had been addressed and 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.

8 to 9 May 2019

During a routine inspection

BPAS Merseyside is operated by British Pregnancy Advisory Service (BPAS). BPAS is a national charity and around 97% of patients are funded by the NHS. The Merseyside clinic has six screening rooms, three consulting rooms and one treatment room. It operates surgical lists from Wednesday to Saturday. There are three satellite clinics at St Helens, Warrington and Wigan.

The service provides termination of pregnancy services for women from Merseyside and surrounding areas as well as patients from Ireland. The service also provides vasectomy services.

We inspected this service using our focussed inspection methodology. We carried out an unannounced inspection on 8 and 9 May 2019.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The main service provided by this clinic was termination of pregnancy services.

Services we rate

We did not previously rate this service. We rated it as Requires improvement overall.

We found areas of practice that require improvement:

  • At our previous inspection in 2016 we were not assured that medicines were regularly reviewed and replaced as required. During this inspection, we found the service did not consistently follow best practice when prescribing, giving, recording and storing medicines. We found out of date medicines in the clinic rooms and on the emergency drugs trolley and the controlled drug register was not always accurately completed. Staff did not monitor the ambient room temperature where medicines were stored.

  • At our previous inspection we found local governance arrangements did not ensure the identification, mitigation and monitoring of risks or the improvement of quality and patient outcomes. Although the service had introduced new systems following this inspection the systems used to monitor performance and risk were not robust. There was now a local risk register in place. However, the local risk register did not have control measures and review dates for all risks identified.

  • We found areas where audits indicated high levels of compliance with policy and procedure, however we saw examples of poor practice or policies not being adhered to by staff. For example, staff did not fully complete all risk assessments prior to care and treatment and staff did not consistently adhere to the infection prevention and control measures specified by the service.

  • The service did not meet the requirements of the duty of candour regulation. Duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person. The service did not always include an apology in the written notification to the patient and only sent a written notification when the patient had given permission, as stipulated within BPAS policy.

  • Patients could not always access the service when they wished. The waiting time for initial consultation was not in line with national guidance and 24% of patients waited longer than 10 days from decision to proceed to termination of pregnancy.

  • Managers were not empowered to make changes to improve services at a local level. Policy was set by BPAS nationally and staff told us this could not be changed or developed locally. The governance structure and audit schedule were set out nationally and managers did not adapt this to local needs or issues. The results of the staff survey could not be broken down into each clinic, so managers did not have an oversight of issues raise by staff specific to their service.

However,

  • The service had clear systems in place to identify and report safeguarding concerns. Staff had received appropriate safeguarding training and knew how to apply this. Staff were supported by a national safeguarding lead.

  • The service had suitable premises and equipment and looked after them well. The clinic had undergone a recent refurbishment, and this was evident in a warm and welcoming environment. All areas of the clinic were visibly clean and clutter free. The clinic was wheelchair accessible with accessible toilets and a lift to all floors.

  • The service had 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. Managers acted to recruit to vacancies and used agency staff as necessary. Staff received mandatory training and an annual appraisal and compliance rates were high for both.

  • We saw staff had a caring and compassionate approach to all patients. Feedback from patients was positive about how staff treated them. Staff demonstrated a non-judgemental attitude that was commented on and appreciated by patients.

  • Managers promoted a positive culture that supported and valued staff. Staff spoke highly of managers and leaders stating they had ‘amazing’ support from managers. The position of management offices next to the reception desk provided visible leadership support at the front door and meant a senior member of staff was on hand quickly in the event of an issue or complaint.

  • The service had recognised that governance processes needed strengthening following our last inspection. There was a corporate governance committee structure in place. The clinic followed the BPAS planned programme of auditing and monitoring and reported audit outcomes appropriately through the governance structure.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with two requirement notices that affected BPAS Merseyside. Details are at the end of the report.

Nigel Acheson

Deputy Chief Inspector of Hospitals

11 May 2016 and 9 June 2016

During a routine inspection

  • There was no robust system in place to ensure that resuscitation equipment was regularly checked to keep patients safe. It was not clear whether several pieces of equipment used in theatre had been subject to the appropriate maintenance tests.

  • The service had reported 11 serious injury notifications to the CQC from January 2013 to March 2016 (eight of which were reported between January 2015 and March 2016). All of these incidents resulted in patients being transferred to the local NHS trust for emergency care. Investigation reports completed following each serious incident did not identify and consider all relevant information and contributory factors

  • Infection control procedures were not always followed in theatre and we were not assured that medication was regularly reviewed and replaced as required.

  • Whilst most services offered by the provider were in line with current RCOG guidance, the practice of simultaneous administration was not in line with current RCOG guidance. BPAS currently offered treatment for early medical abortions either by way of the simultaneous administration of the medicines necessary to effect a termination of pregnancy (only for pregnancy under 9 weeks) or initial dose followed at some point within a 72 hour window with a second medication. The provider no longer offers an interval of 6-8 hours between administrations of the medications because the outcomes with this interval were not found to be significantly better than with simultaneous administration.

  • The service had agreed standards in place with commissioners. Whilst quarterly monitoring reports to the commissioners gave details of service delivery, they did not include details of agreed targets so it was not clear how well the service was performing. It was also not clear how this information was used to improve service delivery or patient outcomes.

  • Patients were not informed about the statutory requirement of HSA4 forms. Staff did not explain to patients that these details were sent to the Department of Health and that it was a legal requirement.

  • A quarterly monitoring report to one of the commissioners showed patients were not always seen within RCOG recommended timeframes. The reasons for delays or extended waiting times were not given in the report but it was possible that these delays were due to patient choice.

  • Local governance arrangements did not ensure the identification, mitigation and monitoring of risks or the improvement of quality and patient outcomes. We were not assured that the registered manager had full understanding and grip of the potential risks within the service and the supporting clinical governance arrangements. When asked to supply the full root cause analysis investigation reports following the recent serious incidents, the registered manager was not clear on who had completed the investigation reports, had not been involved in the production of the investigation reports and had not had sight of the full investigation reports. She was unaware that staff did not have sight into the outcomes of the serious incident reviews.

  • There was no local risk register or other document that identified local risks and the control measures in place.

  • Information from corporate and regional governance meetings should have been shared with staff via staff meetings and nurses meetings. However, we did not see minutes from any staff meetings where this information was shared despite requesting them. Bank and agency staff were not informed of any changes and were not invited to any BPAS staff meetings.

However:

  • The service had clear systems in place to identify and report safeguarding concerns. Staff we spoke with were aware of the safeguarding policy and who to report their concerns to.

  • The clinic followed the BPAS planned programme of audit and monitoring. Audit outcomes and service reviews were reported to the governance committees and Regional Quality, Assessment and Improvement Forums (RQuAIF).

  • Appropriate systems were in place to obtain consent from patients and consent was well documented in the patient record.

  • BPAS had various competency frameworks in order to support the training and development of staff. All medical staff and 89% of registered nurses had undergone an annual appraisal in the last full year (January to December 2015).

  • We observed staff using a caring and compassionate approach particularly in the recovery room where patients were transferred after surgery. Patient feedback forms indicated the majority of patients felt listened to and felt that their confidentiality was maintained. They also indicated the majority of patients would recommend the service.

  • The service was planned and delivered to meet the needs of patients. Following work in partnership with Antenatal Results and Choices (ARC) the decision had been made to provide terminations of pregnancy for foetal anomalies.

  • There was a corporate governance committee structure in place to capture and discuss identified risks. The framework also enabled the dissemination of learning and service improvements and a pathway for reporting and escalation to the BPAS board.

  • The provider had recognised that local governance processes needed strengthening and had recently employed a risk management and client safety lead who was responsible for reviewing systems and was working with registered managers to implement systems such as a local risk register and improved incident reporting systems.

  • Practising privileges were reviewed annually by the medical director and registered manager. The clinical department at Head Office flagged when an individual’s practising privileges were due. Clinicians had a month to submit the necessary documentation otherwise their practise was suspended until the information was provided.

29 January 2014

During a routine inspection

Patient's being supported by the service told us they were satisfied with the standard of care and support provided by the staff team. They made various positive comments such as:

"Everything has been explained to us at every step" and "We have no complaints, the staff have been there throughout the visit answering all our questions."

Various quality assurance checks on the service helped to show systems were in place to ensure that the service was effectively managed and had evidence of being compliant and promoted good practices. Appropriate systems were in place in regard the event and management of emergency procedures and auditing of the standard of record keeping within the service.

Staff were positive about working for the service and felt they were well supported with their training needs to be able to meet patient's individual needs.

24 January 2013

During a routine inspection

We spoke with two people who had used the service. People said they had been happy with the care and treatment they had received at the clinic. They told us that all options had been discussed with them before they decided which treatment to undergo. They said they had been treated with respect and their privacy had been maintained at all times. People had been offered appointments promptly and to suit their needs. People's needs were assessed and they agreed a pathway of care which ensured their needs were met safely.

Staff were described as being polite, friendly, non judgemental and caring. People told us they felt safe at the clinic and staff were good at their jobs.

There were high standards of cleanliness and infection control at the clinic and medical and non medical equipment had been regularly checked to ensure it was safe to use.

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.