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Inspection carried out on 16 May 2019

During a routine inspection

BPAS Peterborough is operated by British Pregnancy Advisory Service. BPAS Peterborough provides consultation and early medical abortion (EMA) and medical termination of pregnancy up to 10 weeks gestation and surgical termination of pregnancy up to 13 weeks gestation. There is one treatment room where surgical termination of pregnancy by vacuum aspiration is undertaken, with the options of local anaesthetic and/or conscious sedation for pain management. This is performed as day case surgery and no overnight accommodation is provided. The service had two ultrasound screening rooms and five consultation rooms.

The service provides termination of pregnancy, sexual health screening and family planning services. We inspected this service using our comprehensive inspection methodology. We carried out an unannounced inspection on 16 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.

Services we rate

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

We found the following areas of good practice:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.
  • Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.
  • 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. Managers regularly reviewed and adjusted staffing levels.
  • Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care.
  • The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.
  • The nursing team were highly committed to giving patients a personalised service. Care was delivered by an exceptional team.
  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
  • The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care.
  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
  • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
  • Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work. The service had an open culture where patients, their families and staff could raise concerns without fear.
  • Leaders and staff actively and openly engaged with patients, staff and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.
  • All staff were committed to continually learning and improving services. Leaders encouraged innovation.

We found areas of outstanding practice:

  • Staff always took people’s personal, cultural, social and religious needs into account and found innovative ways to meet them. For example, using alternative equipment so that the patient wouldn’t have to hear the sound of a vacuum to alleviate their anxiety about the noise and allowing patients to be accompanied by a relative.
  • Consideration of patient’s dignity was consistently embedded within all staff member’s practice. One patient had returned to the treatment unit on the day of our inspection after bleeding heavily, staff ensured provided her with reassurance and clothing to ensure she was comfortable leaving the treatment unit.

We found areas of practice that require improvement:

  • Waiting times from referral to treatment were not in line with national standards.

Heidi Smoult

Deputy Chief Inspector of Hospitals (Central)

Inspection carried out on 17 May 2016

During a routine inspection

The Care Quality Commission (CQC) carried out an announced comprehensive inspection at British Pregnancy Advisory Service (BPAS) Peterborough on 17 May 2016. This service was inspected as part of a wider programme to inspect providers of acute independent healthcare.

BPAS Peterborough provides consultations, ultrasound scans, medical and surgical termination of pregnancy, and counselling and support for people who use the service. In addition, long acting reversible contraception and sexually transmitted infection testing and screening are offered. BPAS Peterborough also provides services via one treatment unit (BPAS Cambridge).

BPAS Peterborough provides consultation, early medical abortion (EMA) and medical abortion treatments up to 10 weeks gestation and surgical treatment up to 13 weeks gestation. Surgical termination is carried out under local anaesthetic by vacuum aspiration.

Our key findings across all the areas we inspected were as follows:

Are services safe at this hospital?

Staff we spoke with were confident to report serious incidents, whistleblow or challenge if they suspected poor practice. Incidents, near misses and serious incidents were standard agenda items at BPAS Regional Quality, Assessment and Improvement Forums (RQuAIF).

Staff adhered to “bare below the elbows” and were observed to undertake appropriate hand decontamination to reduce the risk of infection. Recommendations identified in recent infection prevention and control (IPC) audits (BPAS hazardous waste inspection and the May IPC audit) had been actioned.

All the equipment reviewed during the inspection had been serviced by an appropriate contracted company and maintenance dates were visible on the equipment.

There were systems in place for medicine management that included obtaining, recording, handling, storing and security of medicines.

All eight staff had undertaken BPAS training for safeguarding vulnerable groups - level three. Staff were knowledgeable about safeguarding concerns and documented evidence demonstrated that safeguarding assessments had been completed and appropriate safeguarding referrals had been made for patients under the age of 16.

Evidence of risk management and accountability for the treatment unit in Cambridge was not provided. Specifically in relation to checking of the emergency equipment, ensuring a risk assessment or service level agreement was in place for appropriate care of a deteriorating patient and consideration of a risk assessment in relation to lone working safety requirements. Staff at a local level had not received any training on dealing with violence and aggression.

Not all references to national guidance and standards listed in the Medicines Management Policy 2015 were the most up to date version, despite a recent review. Subsequent data provided following the inspection stated that the Medicines Management Policy 2015 policy had been under review by the clinical governance committee (CGC) at the time of inspection. However no material changes were made to the reference documents or the BPAS policy as a result of this review.

Are services effective at this hospital?

Policies were accessible for staff and there was a system in place for auditing and review via regional and provider level clinical governance. There was a system for patient clinical outcomes to be reviewed at regional and provider level. Staff we spoke with stated that outcomes were discussed at local team meetings. However, this was not minuted.

All staff were appropriately qualified and had received training in accordance with their role. One-hundred per cent of registered nurses had undergone an annual appraisal and 80% of administration staff.

Training data provided demonstrated that both registered nurses and the registered midwife at BPAS Peterborough had received consent workshop training in line with the provider policy.

Are services caring at this hospital?

Staff offered a good service to patients and were helpful, caring and treated patients with dignity and respect. We observed that staff adopted a non-directive, non-judgemental and supportive approach to patients seeking and receiving treatment for termination of pregnancy.

Views from patients were positive and described staff as caring. Results from the patient survey, December 2015, were 100% for confidence and trust in staff and patients treated with dignity and respect.

Staff were clear on the range of emotional responses that women and those close to them may experience during and following a termination.

Staff were recruited in accordance with the BPAS Recruitment and Selection Policy and Procedure, which explored whether candidates were pro-choice. BPAS did not employ or subcontract individuals with a conscientious objection to abortion, or those who did not embrace the organisational beliefs.

Are services responsive at this hospital?

Services were planned and delivered in a way that met the needs of the population and reflected the importance of flexibility and choice for patients. Commissioners and stakeholders were involved in service planning.

Data provided between January and December 2015 demonstrated that 77%of patients received treatment below 10 weeks gestation at BPAS Peterborough, which was above the national average.

Data provided demonstrated that BPAS Peterborough was achieving the target that patients are offered an appointment within five working days of referral or self-referral, as per RSOP 11, in the majority of cases. Achieving between 81% and 91% in each quarter of 2015/16. The percentage of patients receiving a termination procedure within five working days of the decision to proceed was between 73% and 85% in each quarter of 2015/16.

Midwives and nurses undertaking assessments had a range of information that they could give to patients as required. Translation services were available for patients who did not have English as a first language.

There was a complaints procedure in place, and posters displayed in the clinic to inform and encourage people to raise concerns where necessary. There had been no complaints reported between January and December 2015.

We were informed that there were plans to improve capacity and flow. A business case was being developed to increase the number of days the Peterborough centre was open and increase the number of surgery days per month with the aim to reduce waiting times.

Are services well-led at this hospital?

Governance took place at regional and national levels however data provided did not demonstrate this at a local level.

Risk processes were not effective at location level. The centre manager was not trained in risk management and there was a lack of risk assessments to show a proactive approach to risk management at location level.

There was no risk register to enable risks to be identified, managed and reduced in a timely manner.

There was a lack of ownership or responsibility for processes and risk management at the Cambridge treatment unit.

Staff we spoke with stated that team meetings were utilised to discuss incidents, outcomes, complaints and ensure learning. However, team meetings were not minuted, so there was no official record of agenda items discussed or actioned at the meetings.

However, staff were aware of the vision and strategy at BPAS Peterborough, which was to deliver high quality care, promote good outcomes for patients and encompass key elements such as involvement, kindness, a non-judgemental approach and choice for patients. The culture was viewed as supportive and corporately led.

Processes were in place to make sure that the certificate(s) of opinion HSA1 were signed by two medical practitioners in line with the requirements of the Abortion Act 1967 and Abortion Regulations 1991 and the subsequent arrangements for submission of HSA4 forms.

Patient and staff engagement was good, with positive comments of a friendly environment where patients and staff were valued and respected.

We saw the following area of good practice:

  • Staff were described and observed as being non-judgemental.

However, there were areas of poor practice where the provider needs to make improvements.

Importantly, the provider should:

  • Ensure that senior staff at a local level receive training and development with regard to risk management.
  • Ensure clear guidelines are provided to evidence who is accountable for managing and checking emergency equipment at the treatment unit.
  • Review local risk management practices, such as local risk registers and risk assessments for the treatment unit staff regarding safety, management of deteriorating patient, equipment and environment.
  • Ensure that staff at a local level have access to violence and aggression training.
  • Ensure team meetings are minuted to demonstrate good communication and engagement of all staff at all times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 23 January 2014

During a routine inspection

We spoke with three people who were using the service. They were well informed about the treatment options and felt supported to make decisions. They told us they had discussed consent with the nurses in the clinic who had made it clear they could change their decision following their initial consultation in the run up to treatment or on the day of treatment.

We reviewed four sets of records and saw they contained information about the length of the pregnancy, the person�s medical history, treatment provided and plans for discharge and follow up. We saw copies of the legally required certificates signed by two authorising doctors.

There was an infection control plan in place which described the provider's plan for complying with the required standards. This included risk assessments for people using the service and the clinical environment.

We looked at staff records and found they all contained the required recruitment documentation. The provider had arrangements in place to ensure people received treatment from suitably qualified staff.

Inspection carried out on 10, 15 January 2013

During a routine inspection

People we spoke with confirmed that their consent was obtained before any procedure was started. They were provided with enough information in a format suitable for them and they were able to change their mind about treatment options.

Care records were clear and were written in enough detail to provide guidance to staff members and an audit trail of the care provided to women. Women we spoke with said staff supported them during their treatment and with their care needs.

Medicines were stored appropriately and accurate records were kept to show those administered during each woman�s treatment at the service.

Recruitment checks were not all carried out or obtained prior to new staff members starting work with the service. This was partly rectified during our visit, although this did not ensure staff members were safe to work.

There were systems in place to regularly check and monitor the way the service was run. Every woman using the service was given the opportunity to comment about their experience and the service they had been given.

Inspection carried out on 22 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.

Inspection carried out on 29 November 2011

During a routine inspection

People who we spoke with said that they were satisfied with the information that they had received, including information before and after their treatment.

One person told us that the staff were, "Very helpful. They made me feel comfortable, when I was being treated and they told me what I should expect to happen".