BPAS - Birmingham South

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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of patients who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question requires improvement. At this inspection the rating changed to good. This meant the service was consistently managed and well-led.

At our previous inspection, we found the service was in breach of regulations relating to good governance. Governance arrangements were not sufficiently robust or effective to always identify concerns and risks. At this inspection, these issues had been resolved.

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.

The service had a shared vision, strategy and culture. There was a BPAS 2025 to 2028 strategy for all clinics to follow.

The BPAS Birmingham South strategy was based on the BPAS provider 6 pillars vision and strategy: our patients, our care, our voice, our finances, research and innovation and our infrastructure. This had been produced in line with the national strategy.

Service leaders held strategy days to review the vision and strategic direction, which were then shared and discussed with staff. Outcomes from staff surveys were also reviewed during these sessions. The top 3 issues identified were staff morale, communication, and financial rewards. The service responded by making prompt improvements, particularly to communication. For example, as well as daily surgical huddles, a daily all-staff huddle was introduced. Staff reported that this helped them plan the day’s workload more effectively and stay informed of key updates.

The service maintained a risk register and used this to identify areas for improvement and track actions, supporting ongoing development and effective governance.

Staff reported feeling respected, supported, and valued within the organisation. They remained focused on meeting the needs of patients and worked collaboratively to achieve positive outcomes.

Staff spoke positively about their roles and demonstrated a sense of pride in working for the organisation, reflecting a committed and motivated workforce.

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.

Leaders demonstrated the experience, capacity and capability required to deliver the organisational vision and effectively manage risks. The service operated under a triumvirate leadership model, comprising a regional clinical lead, an operations manager and a quality matron. Day-to-day management of the service was undertaken by a treatment unit manager and a lead nurse.

Managers reported feeling well supported by the senior leadership team and highlighted that the organisation placed a strong emphasis on developing and progressing its staff.

Staff told us leaders were visible, approachable and supportive. Leaders had a clear understanding of the challenges and priorities relating to the quality and sustainability of the service. Leaders told us, and staff confirmed, that staff had access to appropriate support, supervision and development to carry out their roles effectively.

Staff felt their views were listened to and leaders actively encouraged engagement. For example, staff were invited to attend team away days, where they contributed to discussions about the vision and direction of the service and were able to provide feedback.

There were processes for providing all staff at every level with the development they needed, including high quality yearly appraisals and career development conversations.

Senior managers attended regional meetings with the senior leadership team where they received updates, discussed governance, performance and shared learning.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff and leaders acted with openness, honesty and transparency.

Staff were encouraged to speak up and to raise concerns. Leaders promoted the value of speaking up. The service had a dedicated Freedom to Speak Up Guardian (FTSUG). The Guardian’s role was to support workers to speak up when they felt they were unable to in other ways. Staff told us they would approach them if they felt it was needed but would generally approach their line manager in the first instance for support and guidance.

There was a good culture of speaking up where staff felt safe to raise concerns without fear of detriment. Concerns were handled sensitively and confidentially and mindful of people’s rights and responsibilities. Staff told us they raised concerns and received positive feedback. They felt these were received in a constructive manner, acknowledged and where possible acted upon.

All staff had completed freedom to speak up training and managers had completed freedom to speak up – listening up training.

The service promoted equality, diversity and inclusion within its workforce. Staff worked to support an inclusive and fair culture and to improve equality of access and outcomes for patients.

There was an up-to-date equality and diversity policy. Training in equality, diversity and inclusion formed part of the mandatory training programme, and 95% of staff had completed this.

The service carried out equality impact assessments for new policies. This helped to ensure that policies, practices and decision-making processes were fair, did not create barriers to participation, and protected people with protected characteristics from discrimination or disadvantage.

The service had clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment and support. Staff acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

At our previous inspection, we found the service was in breach of regulations relating to good governance. Governance arrangements were not sufficiently robust or effective to always identify concerns and risks. At this inspection, these issues had been resolved.

Staff understood their role and responsibilities. Managers could account for the actions, behaviours and performance of staff. There was a well-led and effective clinical governance structure with clear systems and processes. Leaders supported the service’s managers with compliance.

The service had effective systems, such as audits and risk assessments, to monitor the quality and safety of the service. There was a comprehensive audit schedule of clinical and non-clinical audits.

Information from risk and patient management systems was reviewed on a monthly and quarterly basis to identify trends in patient outcomes and clinical quality that required action. Performance dashboards and the local clinical audit compliance board (LCACB) were used to monitor, benchmark and discuss performance at monthly senior management team meetings. These were also accessible to treatment unit managers, enabling them to review and compare their performance against other treatment centres.

We reviewed Midlands LCACB data for December 2025, January 2026 and February 2026. BPAS Birmingham South generally compared favourably with other units across the West Midlands in most areas. However, infection prevention and control (IPC) audit results fell slightly below other units in December 2025 to February 2026. There were action plans to address identified concerns and drive improvement.

The service had a risk register, risks were rated to identify the highest risks. Measures and controls to manage the risks were recorded and review dates were noted to ensure risks were monitored. The top 2 risks for the clinic related transferring of patients in an emergency and the service had actions to mitigate risks and future planning for resolution of the risks. These were on the risk register as part of the ongoing monitoring processes, to ensure transfers were safe and that the responses from partners were timely and effective.

Staff told us they were sent communications regarding any updates in policy and audit results if they were unable to attend team meetings. Quality improvements were also displayed on noticeboards at the service for staff to read.

At the previous inspection, it was identified that not all notifiable events were reported in line with mandatory legal reporting requirements. This had since been addressed, with improvements made to the reporting processes. The service ensured that all required notifications were completed, including the accurate submission of patient analysis data for each termination of pregnancy to the Department of Health.

There was a structured approach to recording, investigating and learning from patient safety incidents. All incidents, including complications and near misses, were reported through the correct statutory reporting system and reviewed appropriately, and used to identify risks and drive improvement.

The service also identified and reinforced areas of good practice following incident reviews, including an open and transparent culture, clear and comprehensive documentation, appropriate follow-up arrangements, and a strong commitment to learning demonstrated by those involved.

There were robust arrangements for the availability, integrity and confidentiality of data, records and data management systems. Information was used effectively to monitor and improve the quality of care.

The provider had an effective approach to assessing and managing the impact of extreme weather events on patients and the service, including flooding. Prior to our visit the service had been affected by severe weather conditions which meant some staff shortages and changes to the surgical list. There was a thorough incident report and detail of the actions taken to protect patients and maintain a service.

The team completed monthly Simulation Based Education (SBE) which was a scenario set by the head office training department. Themes included the disruption of services and saw emergency planning was a regular scenario, enabling exploration of actions. Staff also told us they had recently experienced disruption to the service due to a power outage and had used the SBE to manage the service and a full acute service disruption review had been completed.

The service understood its duty to collaborate and work in partnership to ensure services worked seamlessly for patients. Staff shared information and learning with partner organisations and collaborated to support continuous improvement.

There were well-established relationships with local stakeholders, including the integrated care board (ICB), primary and secondary care providers, and support services such as contraception and sexual health services.

The service had effective systems to share information with local GP surgeries. Patients were asked for consent to contact their GP. Where consent was provided, GPs were contacted to obtain relevant information such as medicines, medical history and any safeguarding concerns. GPs also received a copy of the discharge letter to ensure continuity of care.

The service had transfer agreements with local NHS trusts to ensure the safe transfer of patients in both emergency and non-emergency situations. An external provider notification form was used to report instances where patients presented at other services with complications.

The service had established relationships with over 40 NHS abortion providers to support referrals for patients with complex needs. Staff worked collaboratively with these providers and shared learning to improve outcomes and ensure patients could access services not available locally.

The service contributed to wider system working and improvement initiatives. For example, they supported a project to provide patients with improved access to contraception on maternity wards.

The provider worked in partnership with advocacy organisations and networks to promote reproductive choice and support improvements in legislation. They collaborated with organisations focused on public health, human rights and community wellbeing.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for patients. Staff actively contribute to safe, effective practice and research.

Staff and leaders had a good understanding of how to make improvement happen. The approach was consistent and included measuring outcomes and impact. Examples of learning were shared across the organisation. There was a structured approach to recording, investigating and learning from patient safety incidents. All incidents, including complications and near misses, were reported through the Learn from Patient Safety Events (LFPSE) system and partners were informed through statutory processes. These incidents and events were reviewed appropriately and used to identify risks and drive improvement.

We saw evidence of learning from a no-harm incident in which a patient was given an incorrect intravenous flush. This was reviewed in line with the service’s learning from incidents framework, and actions were taken to reduce the risk of recurrence. These included the introduction of a pre-filled sterile syringe containing saline, the publication of SBAR guidance to support surgical safety. Learning was shared with staff through a ShELS session.

There were processes to ensure that learning happened when things went wrong, and from examples of good practice. Leaders encouraged reflection and collective problem-solving.

Staff were supported to prioritise time to develop their skills around improvement and innovation. The service worked collaboratively with sexual health services and had developed a contraception referral pathway to support patients, including young people, to access appropriate services. Sexual health providers delivered training to non-medical prescribers, including contraception and sexual health training, and were planning additional training in coil fitting.

At our previous inspection, pregnancy remains were not always stored following the provider's policy or best practice. Since this inspection the service had used the learning and audits completed in October 2025 and January 2026 has scored 100%.

Leaders encouraged staff to speak up with ideas for improvement and innovation and actively invest time to listen and engage. There is a strong sense of trust between leadership and staff. At the team vision day agenda items included discussions about innovations or improvements that would a difference to patients and the service they offer, how best to encourage staff to share ideas on improvement and shaping the future of the service.

The service contributed to wider system working and improvement initiatives. For example, they supported a project to provide patients with improved access to contraception on maternity wards.