BPAS - Birmingham South

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that patients and communities had the best possible outcomes because their needs were assessed. We checked that patient’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring patients were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

We found that consent to care and treatment was discussed and explained to patients.

At our last assessment we rated this key question good. At this inspection the rating remained good. This meant patient’s outcomes were consistently good, and patient’s feedback confirmed this.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The service made sure patient’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Patient’s communication needs were assessed and met to maximise the effectiveness of their care and treatment. Staff used telephone interpreters at the initial booking process and offered throughout the treatment journey.

Patients were actively involved in the assessment of their needs, with appropriate support provided where required. The service accepted self-referrals, and a comprehensive approach was taken to ensure each patient’s individual circumstances were fully assessed.

Staff demonstrated a strong commitment to delivering care in line with the most up-to-date, evidence-based practice and national guidance. This ensured that care was tailored to individual needs and focused on achieving the best possible outcomes for patients.

Patients completed a medical questionnaire and initial triage questions when booking through the telephone service. This ensured that relevant clinical information was gathered at the earliest stage.

Triage questions were tailored to patients' responses, prompting further detailed questioning where appropriate. The service had clear criteria to determine suitability for treatment, particularly where underlying health conditions were identified. This ensured patients were directed to the most appropriate clinical pathway based on their individual needs and risk factors.

For example, patients who had undergone more than three previous lower segment caesarean sections (LSCS) were not considered suitable for surgical termination of pregnancy (STOP) at the service due to the increased risk of complications such as bleeding. These cases were referred to a GP for referral to a specialist service.

The service electronic patient record system enabled staff to identify and record when a patient required additional support, allowing the care pathway to be adapted accordingly.

Staff made reasonable adjustments to ensure patients were fully supported throughout their journey. Examples included providing a dedicated support person, offering extended appointment times or earlier appointment times, and adapting communication methods where a patient disclosed a learning disability or additional communication needs.

Patients’ social circumstances were assessed as part of their care, and support was arranged post-discharge where required. The service held multidisciplinary meetings to discuss more complex cases, involving social services where appropriate, to ensure a coordinated approach to care and develop appropriate support plans.

Patients also received a post-procedure follow-up call, providing an additional opportunity to assess wellbeing, address any concerns, and ensure ongoing support needs were met.

Staff had received training to support them to engage with patients with additional needs. Data showed 95% of staff had completed training on learning disability and autism.

The service planned and delivered patient’s care and treatment with them, including what was important and mattered to them. Staff did this in line with legislation and current evidence-based good practice and standards.

We reviewed the theatre register, which provided a clear record of procedures undertaken, including patient details, staffing and timings. This supported effective monitoring of surgical activity and safe practice within the theatre environment.

Patients received care, treatment and support that was evidence-based and in line with good practice standards. There was a national team within BPAS who reviewed national legislation and updated policies and procedures in line with these. This included National Institute for Health and Care Excellence (NICE) guidelines and Royal College of Gynaecology (RCOG) guidelines.

Updated policies were reviewed during the monthly Quality and Risk Group meeting. Following this, the updates were disseminated to staff via internal communication channels. Meeting minutes confirmed that changes to the preoperative care policy had been discussed, reviewed, and formally agreed. Managers were responsible for communicating these changes to staff and ensuring that the updated policy had been read and understood. We reviewed several policies including the consent to examination and treatment policy, medicines management policy and safeguarding policy. The polices were up to date and referenced national legislation and guidance.

Staff followed established service-wide governance processes to ensure compliance and maintain standards. Performance and compliance were routinely reviewed through a comprehensive audit schedule, which was documented on the Local Clinical Audit Compliance Board (LCACB). Audits were monitored monthly by the lead nurse and the quality matron, who ensured that action plans were developed and completed to drive improvements in practice. For example, the quality matron had identified that the infection prevention and control (IPC) audit score for the service was 88%, due to an out-of-date disinfectant and non-compliance with uniform standards. An action plan was implemented, with follow-up scheduled for the next site visit and improvements were achieved.

Patient’s nutrition and hydration needs were met in line with current guidance. We observed patients who attended for surgery were offered a hot drink and a biscuit following their procedure.

The service always worked well across teams and services to support people. Staff completed thorough assessments of patients’ needs, and these were shared so patients only needed to tell their story once.

Staff prided themselves on good teamwork and communication throughout the multidisciplinary team. We observed this throughout all areas of the service.

There was a daily surgical huddle at the start of each list where the theatre team discussed each patient individually including any additional needs such as allergies. Risks were discussed and staff were included in conversations about treatment plans.

Managers held daily staff huddles to ensure non-clinical staff were kept up to date with any surgical or appointment changes, staffing updates, and areas of particular concern for the day.

Patient surgical notes and handovers between theatre and recovery followed the Situation, Background, Assessment and Recommendation (SBAR) format. Notes were easy to read and contained pertinent information for transferring patients between teams.

Staff shared information with other termination of pregnancy providers in the area and aligned their policies. They shared safeguarding information about patients when other services needed to be on alert regarding their care.

Information was shared between teams and services to ensure continuity of care, for example when patients were referred between services. The service had direct access into an early pregnancy assessment unit (EPAU).

Staff held multidisciplinary team (MDT) meetings for complex cases to ensure the right care was delivered to the patient. This included social services if the patient was known to them. They created individualised care plans for patients who needed it following MDT meetings.

Patients were asked for permission to contact their GP. With consent, GPs were contacted for information such as medication, medical conditions, or safeguarding concerns and they received a copy of the discharge letter. GPs were informed if a patient decided to continue the pregnancy or presented with a gestation of above 24 weeks for antenatal care.

The service supported patients to manage their health and wellbeing to maximise their independence, choice and control. The service supported patients to live healthier lives and where possible, reduce their future needs for care and support.

The service had relevant information promoting healthy lifestyles and support. Patient’s received contraception advice and had the option of having an intrauterine contraceptive inserted at the time of surgical termination. Contraception for collection contained advice booklets in each pack. Patients could receive oral contraceptive pill prescriptions at the service.

The service supported patients to make healthier lifestyle changes, such as stopping smoking, improving diet, or increasing physical activity and were able to signpost into local services.

If needed the service signposted patients’ drug and alcohol support services, patient’s services, homeless and housing support and services that supported ethnic minority groups. Patients were also given advice on prevention of sexually transmitted diseases and where to seek support or screening.

The service routinely monitored patient’s care and treatment to continuously improve it. Staff ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of patients themselves.

Patient outcomes met agreed expectations as set out in legislation, standards and evidence-based clinical guidance.

The service actively participated in relevant local and national clinical audits, as well as other monitoring activities including service reviews, benchmarking, and peer assessments.

In June 2025, the service also undertook a mock Care Quality Commission (CQC) inspection aimed at identifying opportunities to further enhance patient care. The review highlighted several areas of good practice. Staff demonstrated adaptability to changes in service provision, including the extension of general anaesthetic services to 24 weeks. There was a strong, shared sense of purpose among clinical staff, who consistently promoted compassionate care. Additionally, the service showed strong compliance with safeguarding requirements, supported by a well-embedded safeguarding culture across both clinical and administrative teams. Staff used peer review to identify areas for improvement which was completed by managers who worked outside of the region of the clinic.

The service had key performance indicators (KPI) which were looked at by senior leaders monthly and included escalation of key risks and concerns. KPI’s included waiting times for treatments and consultation. The service produced weekly activity reports to monitor performance. In most weeks, the clinic exceeded its planned number of early medical abortion (EMA) appointments. However, while the service was commissioned to deliver 47 surgical procedures per week, activity was on average around 10 procedures below this target. This shortfall was primarily due to the limited number of surgical appointments available on some days. To address this, the service had implemented a recruitment plan aimed at increasing surgical capacity and reducing the deficit.

The service had effective systems to monitor patient care, treatment, and outcomes. Outcomes were regularly reviewed by senior managers to ensure the quality and safety of care provided. Monitored complications included retained products of conception, ectopic pregnancy, complex safeguarding cases, and instances of excessive pain.

Learning from incidents was actively shared with clinical teams to promote continuous learning and drive improvements in patient safety and care delivery.

Patients had access to a 24-hour aftercare service, and the outcomes were monitored by this team. If there was a theme that developed it would be communicated to the teams.

The service worked with local public health teams and provided data that supported public health teams to identify areas of high termination of pregnancy or repeat terminations which may indicate a need for additional contraception provision or/and sexual health education.

Patients understood their rights around consent to the care and treatment the service offered. Patients were given information about their proposed treatment both verbally and in writing, to enable them to make an informed decision about their procedure. Staff ensured patients were seen alone to minimise the risk of coercion by a third party.

Staff understood the importance of ensuring that patients fully understood what they were consenting to, and the importance of obtaining consent before delivering care or treatment. Referrals to the service were completed through initial telephone consultations, where consent was explained and obtained during appointments. When a procedure was subsequently booked at the BPAS Birmingham South site, consent forms were made available for staff to review. Consent was checked and discussed again when patients attended for their procedure. During our visit, we reviewed patient records and found evidence that consent had been discussed and reviewed appropriately. We also reviewed consent audit data for BPAS telephone hub locations, which showed consistently high levels of compliance, with consent completion rates exceeding 90%.

The service completed training to support staff to understand the importance of consent. However, training completion for consent was 72% which did not meet the service 85% training compliance level. The service told us they had plans for achieving this compliance rate.

All patients self-referred into the service. Records that we reviewed showed that consent was discussed and reviewed at multiple stages throughout the patient’s treatment pathway.

Staff demonstrated a good understanding of consent processes for all patients, including those under 16 years of age. They were knowledgeable about Gillick Competence and Fraser Guidelines, the legal framework relating to assessing a young person’s capacity to consent to treatment.

Patients were given information about the disposal of the pregnancy remains; this was discussed at their initial appointment with the nurse. At our previous inspection, pregnancy remains were not always stored following the provider's policy or best practice. During this assessment we viewed two freezers used to store products of conception. Both freezers were secure and kept locked. Items were stored appropriately in sealed containers, clearly labelled with patient identifiers and dates to ensure traceability. We saw evidence that remains were collected twice weekly, in accordance with relevant regulations and local policy, ensuring timely and respectful management.