BPAS - Merseyside

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.

Good: This meant people were safe and protected from avoidable harm.

The service had a systemic approach to learning. Managers investigated incidents and identified learning and made improvements. There was a strong clear approach to safeguarding. Staff understood and managed risks. The facilities and equipment met the needs of the women and were clean and well-maintained. There were enough staff with the right skills, qualifications and experience.

Improvements had been made to the service including changes to medicine management systems and processes. The service was working through a medicines management action plan.

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.

We scored the service as 3. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had a proactive and positive culture of safety. The service used an electronic reporting system and linked into the national Learn from patient safety events (LFPSE) system for recording and analysing patient safety events that occurred. There were 224 incidents reported from 1 September 2024 to 12 September 2025 for BPAS Merseyside, 8 were graded as moderate harm and the remaining were low or no harm. At the time of the assessment there was one thematic review in progress.

The moderate incidents reported related to issues relating to transferring patients when complications of the procedure were noted. As a result, the patient pathway had been revised to expedite the process and reduce delays with onward transfers.

Staff understood the duty of candour. Duty of candour is a legal obligation for health and care providers to be open and honest with patients when something goes wrong with their care, causing moderate harm or worse. This requires notification, apology and explanation. Staff were open and transparent and gave patients and families a full explanation when things went wrong.

Staff were debriefed and received support after a serious incident. For example, women who haemorrhaged and were transferred to a local NHS hospital were discussed and learning identified. Staff were encouraged to report incidents and patient safety events. Lessons were learned and practice adapted as a result. All incidents reported were reviewed at a weekly meeting within the BPAS service wider team. Staff gave examples of improvements following an incident.

The service worked with other BPAS locations to share incidents and promote patient safety. Incidents were reviewed at weekly divisional meetings. Learning outcomes were identified and escalated if required.

We scored the service as 3. 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 worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people needed to speak to different members of the team.

Safety and continuity of care was a priority throughout peoples’ care journey. Staff worked with partner organisations to ensure women remained safe. There were clear referral pathways with external agencies including the local early pregnancy assessment unit, mental health services, domestic abuse support, sexual assault referral centres and counselling services. Women who were considered high risk for treatment were referred to local NHS maternity units for specialist support.

The service had a centralised aftercare team that could be contacted 24 hours a day, 7 days a week. All women were advised to contact the team if they had any concerns.

The service worked within the legal framework of the abortion act. Women who were outside the legal termination limit were signposted for support, care and treatment with local maternity services.

Women who became unwell or had complications from care and treatment were reviewed by the service or transferred to local NHS hospital.

We scored the service as 3. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Compliance for level 3 safeguarding training was 90% following a 2-day training course. Compliance for level 2 safeguarding training was 94.6%. Staff received training regarding female genital mutilation (FGM) and understood their reporting responsibilities if they suspected abuse.

The service followed Fraser guidelines and Gillick competency when determining a Child's capacity to consent to medical treatment and decisions relating to sexual health.

The service had systems and processes in place to protect adults and children from abuse and unsafe treatment and staff knew how to identify those at risk. The systems and processes were monitored and reviewed. Additional questions were included in the assessment process for young women to assess their sexual safety. Referrals to local authority were documented.

Young women under 16 years of age accessing the service received appropriate support, including social referrals where necessary.

Any young women using the service under 13 years of age were supported and police were contacted under legal statutory notification powers.

We scored the service as 3. The service worked with women 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.

Women were given information about risks and complications involved in having a medical and surgical termination of pregnancy. BPAS Merseyside assessed each initial consultation, and a pre-operative assessment was carried out to ensure the termination of pregnancy was legal, suitable and safe. Women were asked to consent to treatment, verbally and in writing, and acknowledge they understood the risks.

We saw the legal requirement for HSA1 (Health Service Administration) forms were completed by two doctors prior to issuing medication to terminate a pregnancy or surgical treatment was carried out. These were stored electronically in the patient's record.

There were formal processes to respond to medical emergencies including transfer to local NHS hospital if required. The transfers were reviewed and monitored by the service and hospital.

A pre procedure assessment was completed for all women using the service. This included a venous thromboembolism (VTE) assessment for surgery.

The electronic system was used to document formal handovers and listed tasks to completed for follow up and safeguarding actions.

Staff used a modified surgical safety checklist based on the World Health Organisation (WHO) 5 steps to safer surgery checklist (a tool designed to improve the safety of surgical procedures) when undertaking all surgical terminations. There were no surgical procedures on the day of our assessment. We were told the WHO checklist had been amended following review to ensure safety checks were completed. This was due to be audited and reviewed.

We scored the service as 3. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service ensured the premises and equipment were suitable for the intended use and were maintained and stored securely. There was dedicated space for waiting, consultation, scanning, treatment and recovery.

We saw fire safety and health and safety risk assessments were completed and weekly fire alarm tests were carried out every Thursday. There were dedicated fire marshals and fire extinguisher checks were last checked September 2024. Environmental risks were recorded on the risk register and mitigation was in place and monitored. For example, the replacement of the fire escape and building maintenance due to the age of the premises.

Since our last inspection the staff room had been extended and provided more space for staff to use for their lunch breaks.

The resuscitation trolley was fully equipped and checked regularly by staff. Equipment checks were carried out including the ultrasound machine. Staff knew how to report faulty equipment.

We scored the service as 3. 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.

All staff working at the service were familiar with policies and procedures. Staff were experienced, qualified and had the right skills and knowledge to meet women’s needs. Some staff rotated around the satellite units to cover absence or sickness. No bank or agency staff were employed.

The team included Nurse Midwife Practitioners (NMP’s), surgeons, operating department practitioners (ODP), health care assistants (HCA), a sonographer and administrative staff to meet the needs of the women using the service.

Staff recruitment checks were carried out including disclosure and barring service (DBS). Staff received induction training and supervision support. There was a supernumerary period for new staff.

Managers planned rotas to support patient lists which were reviewed regularly.

Staff used an online system to complete mandatory training. Managers monitored compliance with training and ensured staff were allocated time to complete training requirements. Staff had annual appraisals and performance reviews if needed.

The service carried out regular checks on staffs’ professional registration.

We scored the service as 3. 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 patient areas and clinic rooms appeared visibly clean and tidy. Cleaning schedules were in place and staff cleaned equipment in between each patient.

Annual infection prevention and control audits were undertaken and any actions identified as a result were completed.

The service did not report any cases of infection for MRSA, MSSA or C. difficle.

The service had not reported any post procedure infections in the last 12 months. Sterile equipment was stored and labelled in a locked room. Staff adhered to infection control principles, including handwashing.

Clinical and non-clinical waste management service agreements were in place, and a weekly report was emailed to confirm wastage figures.

Action was taken to reduce the risks associated with Legionella in the premises.

We scored the service as 3. 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.

Medicines including controlled drugs and oxygen were stored securely and safely. Medicines were available for use in an emergency.

There were appropriate arrangements for the safe management, use and oversight of medicines, including controlled drugs (CD’s). CD’s are drugs or chemical whose manufacture, possession, and use are regulated by the government to prevent them from being abused.

The service had implemented a new policy and updated staff training for medicines management. Staff were positive about this change, and further improvements were in progress. For example, a new warehouse management system which tracked medicines from supplier to patient to ensure a full audit trail was recorded.

The service had a central pharmacy team who had undertaken an audit of the service medicines management June 2025. They had identified several actions and were working through the list at the time of the assessment.

Medicine refrigerator and room temperature checks were completed to ensure medicines were being stored in line with the manufactures’ guidance.

The service oxygen prescribing was under review due to inconsistencies identified by the provider. A quality improvement project was underway to include oxygen prescription charts to ensure consistency in recording flow, device, stop and start times.