BPAS - Birmingham South

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

We looked for evidence that safety is a priority for everyone and was supported by those with clear roles and responsibilities for safety. People were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. Environments, and equipment, were safe and designed to meet the needs of people using the service.

At our last assessment we rated this key question requires improvement. At this inspection, the rating changed to good. This meant patients were safe and protected from avoidable harm.

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.

The service had a culture of safety and learning that was based on being proactive, open, transparent and professionally curious. People and staff were encouraged and supported to raise concerns to proactively identify, manage and assess risks before safety events happened. Staff were encouraged to learn from safety events. Incidents were thoroughly investigated, and lessons were learnt to continually identify and embed good practice.

The service used learning from incidents to improve safety and quality of care. We saw evidence that learning was embedded into practice and resulted in improvements in the delivery of care and treatment.

The service monitored incidents for themes and categorised these according to harm. Between October 2025 and March 2026, 66 incidents were reported of the incidents 31% were categorised as access, admission, transfer, discharge. Most incidents reported were no appointment available at the date or time needed or issues post discharge for example where a follow up appointment was needed for products of conception tissue check (PTC) following a procedure but own was not available within the required timeframe. These appointments are not always needed but in instances where one was not available staff would find an appointment at an alternative location that suited the patient. If there was a concern post discharge and an urgent PTC was required, the service made a referral to the local NHS trust.

The service categorised the incidents by harm, in the time period 2 were categorised moderate harm and all other patient incidents were reported as no harm or low harm. The 2 moderate harm incidents had been reviewed and action taken for example follow up contact with the patient and referral to a local NHS trust for further investigation. Feedback was also provided to staff following reporting on incidents where a patient needed to be transferred to an NHS hospital, this was a thorough review including timeline of events, review of observations and medical notes and decision to transfer. There was also feedback on what went well and learning for the future.

Incidents were thoroughly investigated, and lessons are shared both internally and externally. The service had monthly ‘Sharing to Ensure Learning Sessions’ (ShELS). These meetings were recorded and minutes detailed incidents and the risk factors. We saw a review of all post-partum haemorrhage transfers from December 2024 and February 2025. The report highlighted any good practice and opportunities for learning and sharing of wider learning with other organisations.

Learning from incidents was shared with staff via verbal communication, newsletters, and meetings. Staff told us any immediate or urgent incident information was shared during the daily staff huddle. Staff were offered training sessions if appropriate following the incident. For example, the team had been given a training refresher on the patient perioperative policy, following an incident where a patient had been transferred from the recovery area too soon.

Staff told us clinic meetings were held every 2 months, they would discuss changes to policies or national guidelines. Situation based education sessions were held monthly. There were simulations of specific scenarios such as emergency evacuations of the premises for learning.

Safety and continuity of care was a priority throughout a patient’s care journey. This happened through a collaborative, joined-up approach to safety that involved patients’ along with staff and other partners in their care. The service worked with social services and community teams where patients had safeguarding or additional needs to ensure they received safe and appropriate care.

There was a good awareness of the risks to patients across their care journey. The approach to identifying and managing these risks was proactive and effective. The effectiveness of these processes was monitored and managed to keep patients safe. There was a comprehensive initial assessment for all patients which included risk-based questions. The service had clearly defined pre‑operative assessment and post‑operative processes.

Staff held daily safety huddles. We observed 1 huddle, this was well attended by staff and included the surgeon, nurses, midwives, healthcare assistants, operating department practitioner and the treatment unit manager. Patients booked for a procedure that day were discussed. Areas discussed included patient-specific concerns, safeguarding considerations, and relevant test results. Patients with extra support needs such as mental health support, a chaperone or interpreter were highlighted and the plan to meet their needs discussed. Staff were informed of any patients with allergies.

During our observation of a procedure, we noted that Instruments, swabs and needles were counted prior to and after the procedure. This was in line with surgical guidance and best practice.

When a patient was moved to the recovery area, we observed the handover between theatre and recovery staff. This followed the Situation, Background, Assessment and Recommendation (SBAR) format. Notes were easy to read and contained pertinent information for transferring patients between teams.

There were systems to support patients who had serious complications in theatre or the recovery area. There was a deteriorating patient policy and staff had monthly practice emergency scenarios to ensure they were competent with dealing with different emergency scenarios. Patients were transferred to the local acute trust if necessary, and staff were able to contact gynaecology teams directly with referral information.

The service had agreements with local NHS trusts for ongoing care if a patient’s health deteriorated or they had concerns. We saw case notes and incident reports that reflected decisions made to transfer a patent to a local NHS trust. Where a transfer was required for further observations, transport would be organised and was funded by the service.

Patients who were unable to confirm the date of their last menstrual period were required to attend the clinic for assessment to establish the gestation of the pregnancy before any treatment was offered.

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

Staff had a good understanding of safeguarding and when they were required to raise any concerns. Safeguarding concerns were discussed at meetings and briefings. Any identified concerns were recorded during the patient’s initial appointment. It was then highlighted within their record to ensure it wasn’t missed at further appointments. These were discussed at the safety huddle, and theatre briefing sessions to ensure staff awareness.

Staff had completed safeguarding referrals to the local authority in line with the service safeguarding policies. Staff were able to give examples of raising safeguarding concerns for both children and adults with the local authority. Records showed safeguarding actions and discussions were documented.

We viewed files for patients under the age of 18 who had attended the service for a procedure. All patients under the age of 18 were automatically flagged as a potential safeguarding risk. The conversations during the assessment were well documented and staff had explored any safeguarding concerns including those at risk of Female Genital Mutilation (FGM), and domestic violence. There was support available to all patients at the risk of FGM and domestic violence.

Patients under the age of 18 who were not accompanied by an appropriate adult, and did not wish to inform their parents, were supported by staff at the service who made the appropriate safeguarding referrals.

Staff completed mandatory safeguarding training specific to their role. Clinical staff were trained to safeguarding adults and children level 3, this was a bespoke 2-day face-to-face training package mapped in line with the safeguarding intercollegiate document. Non-clinical staff were trained to safeguarding adults and children level 2. The service met its compliance rate for this training at 85%.

Staff had access to the Child Protection Information Sharing system, enabling BPAS to share information with partners to better protect vulnerable children.

Staff understood the principles of the Mental Capacity Act. When concerns were identified about a patient’s capacity to make decisions about their care, the service held a multidisciplinary team (MDT) meeting with the patient and their support network. Where required, an advocate could be appointed to support the patient, and a doctor could complete the mental capacity assessment on the day of the procedure. Staff completed mandatory Mental Capacity Act training. Completion rates for this training were 100%.

Staff completion rates for PREVENT Level 3 training (in relation to recognising and preventing radicalisation) was 100%.

There service supported patients to understand their individual risks and respected the choices they made about their care. Staff were informed about and understood the risks relating to patients they supported.

Individual risks to patients were assessed, and patients were involved in this process as much as possible. Patients were helped to understand the risks relating to them and what they could do to keep themselves safe.

Staff had completed basic life support training both face to face and via an online course. The online training had been completed by 100% of staff, while 77% of staff had completed the face-to-face training. Overall, this met the service’s 85% compliance target. Clinical staff had also completed immediate life support training, with a compliance rate of 100%.

At our previous inspection, the service did not use a specific paediatric early warning score for children under 16 years of age undergoing surgical termination of pregnancy. At this inspection, we found the service had addressed this concern by updating its early warning score policy. A bespoke template, the Termination of Pregnancy Early Warning System (TEWS), had been developed for the wider organisation, BPAS. This included a separate paediatric form to ensure appropriate monitoring of younger patients.

In all 8 records we reviewed we saw timely completion of venous thromboembolism risk assessments and TEWS completion. Patients’ care plans reflected any risks following a procedure, advice was given to reduce these. Clinical notes were well completed, eligible and signed. Staff recorded comprehensive accounts of discussions with patients, including clear explanations of treatment options and associated risks, to support informed decision-making.

Patients were assessed for suitability for discharge following surgical procedures and were required to meet a set criteria. These included but were not limited to, an assessment of alertness, stable mobility, and confirmation that they had eaten and drunk following the procedure. Staff were observed providing clear explanations of potential side effects of treatments, including guidance on how and when to escalate concerns. Patients were also required to have a responsible adult chaperone, aged over 18 years, to support them for the first 24 hours following the procedure. Staff also gave patients details of where they could seek support following the procedure for example from counselling services. Staff checked that patients had emotional support at home or from friends and family following the procedure. Pain relief to take home was given if required. Where contraceptive medication was prescribed staff explained the dosage and how to take the medication.

Patient notes detailed that clinical observations were comprehensively recorded throughout each stage of the patient journey. Observations were completed at regular intervals in line with national guidance, including baseline observations on admission, intra-operative monitoring, and post-operative recovery checks.

Staff used a standardised proforma to document care from initial assessment through to discharge, ensuring a consistent and structured approach to recording and supporting continuity of care. The service monitored women receiving misoprostol medication (termination medication) closely due to the associated risks, for example vomiting, diarrhoea, and abdominal cramping.

Staff assessed patient risks appropriately. Where a pregnancy was suspected to be outside the uterus, cases were reviewed using a multidisciplinary team approach to determine the most appropriate course of action. Patients with suspected ectopic pregnancy were referred promptly to the nearest acute hospital for emergency treatment. The service had established pathways, including a formal agreement with the local Early Pregnancy Assessment Unit, to support timely access to specialist care.

In the event of patient deterioration within the clinic, staff followed established emergency procedures, including calling 999 and providing life support until ambulance crews arrived. They had haemorrhage kits, to control bleeding and stabilise patients. Records showed there had been 2 reported emergency transfers in the past 12 months.

We observed a discharge discussion taking place in a quiet, private room without interruptions, ensuring patients’ dignity and confidentiality were maintained. Where appropriate, a partner was invited to be present during the discussion.

Staff provided a clear summary of the procedure and revisited key information to support patient understanding. Contraception options were discussed, along with pain management and aftercare requirements. Patients were provided with a surgical treatment guide, including relevant contact numbers for support.

Staff explained what to do in the event of complications, including signs of infection, excessive bleeding, and when to seek urgent medical advice. A 24-hour aftercare contact line was discussed, ensuring patients had access to support following discharge.

Advice on recovery, including activity, exercise and sedation effects, was also provided. We observed that explanations were clear and easy to follow. Patients were informed about counselling support services and how to access them if needed.

The service detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care.

The serviced operated from a 3-storey building that had been adapted to meet the patient needs. There were several clinic rooms, a recovery area and ward, a theatre and storage rooms. There were several admin offices the 3rd floor and 2 waiting rooms.

All equipment was checked prior to procedures. The emergency buzzer in theatre was checked daily.

Resuscitation trolleys were in good condition, equipment was in date and daily checks had taken place. A haemorrhage trolley was available and appropriately stocked to support the prompt management of patients experiencing significant bleeding.

The service had the appropriate equipment at each bed space to ensure that they met the needs of patients using the service.

The service used CCTV across all communal areas, including waiting rooms, stairways, and the main entrance. Access to the building was controlled via a buzzer system, requiring staff to grant entry, which supported the security of patients and visitors.

CCTV monitors were located within staff-occupied areas such as offices and the main reception, ensuring these spaces were continuously observed while patients were accessing the service. This contributed to maintaining a safe and secure environment.

The service managed waste safely, with clearly labelled bins that were distinct from general waste bins, supporting appropriate segregation and disposal.

Staff used equipment correctly to meet statutory requirements and supported patients to stay safe. We saw all single use sterile equipment was disposed of safely and all equipment stored was within date.

The service had plans to manage potential disruption, including from protestors outside the facility or situations where patients required protection from aggressive partners. Robust security procedures were implemented, including links with local police and other support services, to ensure patients could access care safely and without intimidation.

The service made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met patient’s individual needs.

During the assessment, the service was staffed appropriately to meet patient needs. Staffing on the day included 2 midwives, 2 nurses, 3 healthcare assistants, 1 theatre operating department practitioner (ODP) and a surgeon. Additional leadership presence included a lead nurse, an operations manager, the treatment unit manager and a quality matron. Staff we spoke with reported staffing levels were consistently safe. We observed that staffing levels and allocations of patients were discussed during the morning safety huddle, and staff demonstrated a clear understanding of their roles and responsibilities. The service used bank staff to cover shifts when staff were on leave.

All staff including bank staff had an induction. Nursing staff completed a competency workbook to ensure they had the necessary skills to care for patients. This included being competent to provide care during first-stage recovery following anaesthesia. The workbook covered key skills, required regular updates, and included evidence to demonstrate staff competence.

Staff had the right qualifications, skills, knowledge and experience to deliver safe and effective care. Overall mandatory training compliance was 96%. Staff booked themselves onto courses and received email reminders when their training was running out, staff told us they had completed their training. Leaders monitored training compliance rates and received alerts about their staff’s mandatory training.

The service employed midwives, continuity nurses and non-medical midwife prescribers to support continuity of care throughout the patient pathway. Training records showed that midwives received the appropriate level of training in relation to the stages and trimesters of pregnancy.

Staff completed conflict resolution training and training in de-escalation techniques this had been completed by 100% of staff.

Surgeons who attended the clinic were employed under practising privileges (the formal rights granted to a healthcare professional, such as a doctor, to treat patients and perform specific clinical activities within a particular hospital or healthcare organisation). There was a centralised team who ensured all the surgeons had the right checks to be safe at work. At the time of our inspection the service had 1 regular surgeon. There was a vacancy for a second post for an additional surgeon which had been recruited to.

There were robust recruitment practices to make sure staff were suitably experienced, competent and able to carry out their role. We viewed 3 staff files, and all contained the appropriate qualifications for their role.

Managers had undertaken appraisal training and ensured objectives were set and reminders were scheduled throughout the year to ensure the objectives were reviewed and being achieved. Staff we spoke with had received an appraisal or had 1 booked.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service performed well for cleanliness. The service completed monthly and annual infection prevention and control (IPC) audits. Monthly audits consisted of hand hygiene, uniform, environment and sharps audits. All audits’ results between October 2025 and February 2026 scored above 93%. Where there were areas of concern identified, there was an action to improve compliance. For example, the results from the September 2025 IPC audit were 88% because of the waste bags not being closed correctly. The service provided further education for staff on the correct tying of waste bags. Cleanliness standards were benchmarked against other sites within the organisation, and the service performed highly across all assessed areas.

Staff demonstrated a good understanding of IPC procedures. Evidence provided following our inspection showed that 100% of staff had completed IPC training.

The environment was visibly clean, tidy and free from clutter. ‘I am clean’ stickers were in use on equipment, indicating that decontamination processes had been completed and that items were ready for use.

Staff were provided with and used appropriate personal protective equipment (PPE) in line with national guidance and the level of risk associated with care delivery. We observed staff wearing PPE for all clinical tasks, with items changed between patient contacts to minimise the risk of cross-contamination. In theatre, equipment was sterile and either reprocessed off site or single-use and disposed of appropriately after use. Reusable equipment, including trolleys and patient couches, were cleaned between patients. Waste was managed safely, with clinical waste segregated correctly and sharps containers appropriately closed, labelled were stored in line with best practice. Staff were bare below the elbow in line with national guidance and we observed regular handwashing.

Staff held discharge discussions with patients prior to them going home. Patients were provided with clear advice regarding infection risks and were informed of the appropriate actions to take should they have any concerns following discharge.

The service adhered to national and local guidance on infection prevention, including the use of rectal antibiotics for patients undergoing termination of pregnancy where appropriate. This supported effective infection control and contributed to positive patient outcomes.

The service made sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. Staff involved patients in planning, including when changes happened.

Medications for use in procedures were prepared prior to the patient coming into theatre and locked away. Medications were checked by 2 members of staff and the expiry date, dose and patient name noted within the patient notes. Resuscitation medicines required in an emergency followed Resuscitation Council (UK) guidance. The expiry dates were checked on medicines to ensure they were safe to use.

Medicines that required refrigeration were stored securely in a refrigerator. Room and fridge temperatures were checked where medicines were stored.

During and after the procedure we observed patients having their pain levels checked. Patients could be prescribed pain relief, and this was also discussed at discharge conversations.

The service offered a ‘pills by post’ model of care for patients whose pregnancies were less than 10 weeks’. This involved the provision of early medical abortion (EMA) medicines, which were prescribed following appropriate assessment and taken over the telephone. This approach supported timely access to care while maintaining privacy, choice, and convenience for patients.

Patients opting for early medical abortion (EMA) were prescribed medication by a consultant following appropriate clinical review. Patients were able to either collect their prescription to take home or take the medication while attending the centre.

Prescriptions were managed through a centralised system, A consultant reviewed patient records remotely and authorised the prescription, ensuring appropriate clinical oversight and safe prescribing practices.

Patients who presented at the clinic with a confirmed pregnancy of exactly 10 weeks’ gestation were able to receive oral medication on the same day and return the following day for the second stage of treatment. This pathway also applied to patients attending the clinic for ultrasound scanning to confirm gestational age.

Patients with pregnancies beyond 10 weeks’ gestation were required to undergo a surgical procedure in addition to receiving medication, ensuring care was delivered in line with clinical guidance and safety requirements.

We saw that there were two medication-related incidents were reported between October 2025 and March 2026. One incident was due to an issue with a piece of medical equipment, while the other involved a patient not taking pain relief as prescribed.

Patients were offered a choice of pain relief options, including oral analgesia. They also had a choice of sedation, local anaesthetic, and general anaesthetic. Discussions regarding these options were clearly documented and included an assessment of associated risks to support safe decision-making.

Medicines policies, procedures and systems followed current legislation, professional guidance and relevant best practice so that patients’ medicines were ordered, administered, recorded, stored and disposed of safely. Medication administered was kept securely, clearly labelled and disposed of safely. The consultant decided on the dose of medication to be administered, and this was clearly recorded at the time of administration.

Controlled drugs, those drugs which require additional safety checks, were stored, recorded, administered and disposed of safely. Controlled drugs were stored in a secure locked cupboard within a locked office. At the time of our inspection, we identified an issue relating to a controlled drug which, although stored securely and safely, should have been disposed of two weeks earlier in line with BPAS policies and procedures. Staff responded promptly to this finding, and the medication was immediately sent for appropriate disposal.

Local and national audits relating to the safe storage and use of medicines covered areas such as storage conditions, record-keeping, and compliance with Patient Group Directions (PGDs). The service achieved compliance rates of over 94% across all audits conducted between January 2025 and March 2026, prior to our inspection.

Some issues were identified in the audit, including that the controlled drug cupboard access code had not been changed within the required three-month period, in line with provider policy. In addition, controlled drug documentation did not always follow best practice, as errors were crossed out rather than correctly bracketed with a corresponding footnote.

Action plans had been developed to address all issues identified through the audit process.

Patients who received conscious sedation were required to be fully awake, able to walk unaided and must have drank something prior to being discharged.

The service monitored and remained up to date with changes in national guidance relating to medications and medical equipment. For example, updates to medication policies were reviewed and implemented to ensure practice remained aligned with current standards.