BPAS - Merseyside

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 requires improvement. At this assessment the rating has changed to good.

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.
There was an inclusive and positive culture of continuous learning and improvement based on meeting the needs of women who used the service. Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive. Staff understood their roles and responsibilities. Managers and staff worked with the local community to deliver care and treatment in line with national guidance and legislation.

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.

We scored the service as 3. 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 service had a shared vision, strategy and culture. This was based on transparency, equity and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff and leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and women using the service.

Staff were aware of the organisation's values which guided staff and their work to advocate for women’s reproductive choice.

We scored the service as 3. 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.

The service had a clear leadership structure so staff knew who to approach for support and there were clear lines of responsibility. The leadership team had changed since our last inspection.

Staff at all levels told us their leaders were visible and approachable. Staff felt supported by their managers and the wider organisation and knew who to go to for support.

Staff felt respected and valued. They were encouraged to develop their skills and were given development opportunities. Staff were given time to receive additional competence based training in ultrasound scanning, contraception counselling and the insertion of contraceptive devices.

We scored the service as 3. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The staff we spoke with told us they worked in a culture where speaking up was encouraged and valued. The service had a Freedom to Speak Up (FTSU) guardian. FTSU guardians have an independent role within an organisation to listen to, support, and guide workers who feel they cannot use formal channels to raise concerns about patient care or other organisational issues.

Patients and carers had the opportunity to give feedback on the service they received in a manner that reflected their individual needs.

We scored the service as 3. 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.

Staff received training in equity and diversity. Leaders encouraged staff to discuss any reasonable adjustments they needed to improve their working lives.

The organisation had a range of networks to promote visible representation and acceptance of difference within their workforce, and a safe space where people could access advice and information. The networks included a disability equality network, a race equality network, a neurodiversity network, a parent and carers network, a lesbian, gay, bisexual, transgender, queer or questioning network.

BPAS had undertaken equality monitoring of staff within the service to ensure it is diverse in its make-up and representative of the patient group.

We scored the service as 3. 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.

There was a clear management structure at site level. Leaders and staff understood their roles and responsibilities. Leaders monitored the quality and safety of the service and identified where actions should be taken. There was a clear reporting structure with meetings to review the quality and safety of the service. Leaders escalated any concerns or risk to corporate governance meetings that were part of the providers national oversight structure, part of the provider’s wider structure.

There were systems and processes in place to ensure the legal documentation was completed for termination of pregnancy to comply with the Abortion Act 1967.

The service had a risk register. Risks were regularly reviewed to monitor actions identified to reduce risk. Risks scored high and above were escalated to providers national risk managers and reported on the national BPAS risk register.

The highest risks for the service were related to the premises. The outside fire escape required work to make it fit for purpose. Portable air conditioning units were in use in patient and staff areas to cool internal room temperatures. The provider was considering moving the theatre suits to the ground floor to mitigate the risk of issues relating to the lift. We found risks had been assessed and mitigation was in place to control them.

Leaders had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. Leaders had oversight of the audits completed by the clinic so they could ensure any actions required to improve compliance were completed. For example, a monthly Quality Matron divisional report for audit and quality monitored compliance and trend analysis. Actions were reviewed and monitored to ensure the quality of the service was maintained.

Information governance procedures were in place to ensure confidentiality of patient records. This included paper and electronic records. Electronic records were password protected and paper records were stored in locked cupboards.

The service had a business continuity plan to ensure the service would be able to continue to deliver essential care in the face of a disruptive incident. This included providing services at other BPAS locations.

We scored the service as 3. 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 had a positive relationship with the local NHS hospital maternity services and early pregnancy units. They liaised with local authorities regarding safeguarding concerns and other contraceptive services.

Staff knew who to contact and escalate concerns to both internally and externally.

Managers and representatives from the wider organisation had regular meetings with commissioners to discuss contract management and review performance against key performance indicators.

We scored the service as 3. 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 organisation had developed an Integrated Research and Innovation Strategy 2025-2030 which was created with staffs’ input and cooperation. The strategy was available for the public to view on BPAS website. The provider completed internal and external projects that were adding to the evidence base for reproductive and sexual healthcare.

Staff were given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery. Staff told us they were encouraged to share their thoughts with leaders about improving ways of working. We observed a quality improvement board in the corridor. Quality improvements projects under way were to work with the sonographer and sonography team to improve compliance and work with the clinical teams to improve communication.