The Care Quality Commission
  • Hospital
  • Independent hospital

MSI Reproductive Choices Local Treatment Centre - Maidstone

Overall: Good read more about inspection ratings

10-16 Brewer Street, Maidstone, Kent, ME14 1RU 0845 300 8090

Provided and run by:
MSI Reproductive Choices

All Inspections

2 August 2018

During a routine inspection

Marie Stopes International (MSI) Maidstone Centre is part of the provider Marie Stopes International UK (MSI UK). MSI UK is part of Marie Stopes International, a not for profit organisation that was founded in 1976 to provide a safe, legal abortion service following the Abortion Act 1967. The centre registered with the Care Quality Commission on 13 December 2010.

Maidstone centre offers early medical abortion (EMA), medical termination of pregnancy and surgical termination of pregnancy. Medical termination of pregnancy up to nine weeks plus four days gestation and surgical termination of pregnancy up to 14 weeks gestation. Surgical termination of pregnancy is carried out under ‘conscious sedation’ (a combination of medicines to help the patient relax during the procedure), or no anaesthetic according to patient choice. The centre also provides consultations, ultrasound scans, counselling, long acting reversible contraception and sexually transmitted infection screening services. In addition, the service also provides vasectomy (male sterilisation) under local anaesthetic.

We inspected this service using our comprehensive inspection methodology. We carried out an unannounced inspection on 2 August 2018.

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 into account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

At our previous inspection on 25 July 2017 we found breaches in regulations and we served requirement notices in respect of:

  • Regulation 12 Health and Social Care Act (Regulated Activities) Regulations 2014 Safe care and treatment.
  • Regulation 18 Health and Social Care Act (Regulated Activities) Regulations 2014 Notification of incidents.

At this inspection we checked to ensure that these breaches had been addressed.

We rated it as good overall.

Our key findings were as follows:

We found good practice in relation to:

  • The service managed staffing effectively and services had enough staff with the appropriate skills, experience and training to keep patients safe and to meet their care needs.

  • The centre ensured that all patients first consultation was without anyone else present to ensure the patient was protected and allowed them to discuss information in a safe environment.

  • Staff could explain the procedures for safeguarding children, young people and vulnerable adults. They knew the needs and vulnerabilities of children and young people using their service to enable prompt safeguarding referrals.

  • Staff were non-judgmental and treated patients with kindness.

    However we also found:

  • The centre had limited storage for waste. Waste was not separated into bulk storage bins in line with national guidance. All clinical waste was stored in a locked outside cupboard which we observed was extremely full and when opened bags fell out onto the floor posing a potential infection control risk to staff if items split.

  • The environment was challenging throughout with regard to ensuring privacy and dignity for patients. This included consultation areas, waiting areas and recovery.

  • Patients had to wait longer than the centres target to attend a surgical termination of pregnancy which is outside Royal College of Obstetricians and Gynaecologists (RCOG) guidance.

Following this inspection, we told the provider that it should make other improvements, even though a regulation had not been breached, to help the service improve.

Heidi Smoult

Deputy Chief Inspector of Hospitals

18 July 2017 and 3 August 2017

During a routine inspection

Marie Stopes International (MSI) operates Marie Stopes International Maidstone. Facilities include four consulting rooms, one counselling room, one surgical treatment room, two waiting areas, and a recovery area.

The service provides medical termination of pregnancy including early medical abortion, up to nine weeks plus four days, surgical termination of pregnancy, up to 14 weeks, consultations, ultrasound scans, counselling, and support for people who use the service. The service also provides advice on long acting reversible contraception and sexually transmitted infection screening. Surgical termination of pregnancy is carried out under ‘conscious sedation’, by either vacuum aspiration or dilatation and evacuation or no anaesthetic according to patient choice and needs. In addition, the service also provides vasectomy (male sterilisation) under local anaesthetic.

We inspected this service using our comprehensive inspection methodology. We carried out a short notice announced inspection on 18 July 2017, and an unannounced on 3 August 2017.

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 into account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

CQC undertook enforcement action, following an inspection of governance systems at the MSI corporate (provider) level in July and August 2016. There were several breaches of regulation relevant to this location, which we have followed up as part of this inspection.

The breaches were in respect of:

  • Regulation 11 Health and Social Care Act (Regulated Activities) Regulations 2014 Need for consent

  • Regulation 12 Health and Social Care Act (Regulated Activities) Regulations 2014 Safe care and treatment

  • Regulation 13 Health and Social Care Act (Regulated Activities) Regulations 2014 Safeguarding service users from abuse and improper treatment

  • Regulation 17 Health and Social Care Act (Regulated Activities) Regulations 2014 Good governance

  • Regulation 20 (Registration) Regulations 2009 Requirements relating to termination of pregnancy

Services we do not rate

We regulate termination of pregnancy services but we do not currently have a legal duty to rate them. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the following areas of good practice:

  • Staff understood their safeguarding responsibilities and what abuse was.

  • There was a system to ensure all incidents were recorded and monitored, with learning and outcomes shared with staff.

  • Staff we spoke with had a good understanding of duty of candour.

  • Staff were caring, helpful, and respectful.

  • There were policies in place for staff to follow which were updated in line with national guidance. Policies were accessible to staff.

  • Translation services were available for patients who did not speak English as a first language or who had other communication difficulties, which included access to including British sign language and Makaton.

  • All areas we visited were visibly clean and tidy, all equipment was clean.

  • The service had a system for handling, managing and monitoring complaints and concerns.

  • There was a positive culture at MSI Maidstone staff told us leaders were approachable.

  • The provider had introduced a new governance system, however at the time of inspection the new framework was not sufficiently embedded to demonstrate that it was effective.

However, we also found the following issues that there service needs to improve:

  • Waste was segregated correctly, but not all bins were labelled to indicate the type of waste to be disposed of in line with Health Technical Memorandum (HTM) 07-01: Safe Management of health care waste and control of substance hazardous to health (COSHH), health, and safety at work regulations.

In addition, the provider responded promptly to issues raised:

  • There was no formal system for counting equipment and swabs following procedures to make sure none were retained at the end of the procedure. Following our inspection, the centre wrote to us to inform us they recognised they had not undertaken this in line with policy. A visible count board was put in place to make sure the same number of swabs were present at the start and end of each procedure.

  • Six out of 10 termination of pregnancy early warning score had not been completed in line with guidance for completing. This meant that nursing staff might not recognise at an early stage if a patient was deteriorating. Following our inspection, the centre provided evidence of additional training that had been given to staff on the completion of the termination of pregnancy early warning score system. This included competencies for all staff on how to perform and record physiological observations such as blood pressure, pulse and respiration rate. Termination of pregnancy early warning scores were being audited regularly.

  • At the time of our inspection, the centre did not have an action plan or risk reduction strategies in place, following a fire risk assessment undertaken in April 2015. As a result of this, we contacted the local fire and rescue service, who undertook an inspection of the centre in August 2017. Following this inspection, the centre provided evidence that they had commissioned an outside company to create new fire risk assessment, and action plan which was completed. The local fire and rescue service returned in December 2017, to provide further help and guidance.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with three requirement notice(s) that affected termination of pregnancy. Details are at the end of the report.

Professor Sir Edward Baker

Chief Inspector of Hospitals

17 May 2016

During a routine inspection

The Care Quality Commission (CQC) carried out an announced comprehensive inspection at Marie Stopes Maidstone on 17 May 2016. This service was inspected as part of a wider programme to inspect providers of acute independent healthcare. Our role is to ensure that people receive safe, compassionate and high-quality care. Although we don't currently have the powers to rate these services, we report on whether they are safe, effective, caring, and responsive to people's needs and well led. We highlight areas of good practice and areas of improvement.

MSI Maidstone 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.

The centre provides medical termination to nine weeks + four days and surgical termination of pregnancy to 14 weeks. Surgical termination is carried out under conscious sedation.

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.

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

Are services safe at this hospital?

There was an inconsistent approach to action planning and ensuring that lessons learnt from incidents were shared with all relevant staff locally. There was little local ownership of learning from incidents and no clinical oversight.

Staff did not have the appropriate level of safeguarding training to manage safeguarding issues. The policy was not in line with the most recent national guidance. Staff without appropriate safeguarding training were making decisions about the treatment of children attending the clinic. Data provided by the registered manager prior to the inspection showed that only two staff had completed level 3 child safeguarding. Policies did not reflect the most recent national guidance.

Staff did not carry out the five steps to safer surgery checklist, commonly known as the World Health Organisation (WHO) five steps to safer surgery checklist, consistently. Several stages of the checklist were not completed and there was no engagement in the process from the surgeon or anaesthetist.

Infection control systems, processes and practices were not delivered in line with the current national guidance. There was poor hand hygiene, poor use of personal protective equipment and poor pre-surgical preparation.

Staff highlighted long working hours as a frustration at times although they recognised the need for flexibility due to the demands of the job. Heavy workloads, crowded operating and clinic lists and a strict 15 minute consultation time meant best practice was not followed and there were lapses in infection prevention and control procedures and the taking of consent.

However, equipment including surgical equipment, resuscitation and anaesthetic equipment was available, fit for purpose and checked in line with professional guidance.

Are services effective at this hospital?

Whilst policies were accessible for staff and were developed in line with Department of Health Procedures for the approval of independent sector places for the termination of pregnancy services, they were not always updated to reflect practice changes in a timely manner and there was a lack of consultation and engagement of staff to support evidence based care practices.

Staff were concerned that the registered manager was supporting other clinics and was consequently away much of the time. There was no clinical leader for the service and the arrangements for management support whilst the registered manager was absent were unclear and not known to staff.

We had concerns that consent for surgery and termination of pregnancy was obtained by staff who were not appropriately knowledgable or trained to do so.The assessment of whether a child was competent to consent was completed using a basic checklist and staff were unable to describe what triggers would suggest a child lacked understanding. The individual patient records did not show that the other conditions for obtaining consent from a child, such as encouraging them to involve a parent, had been considered. Staff spoken to did not have a good understanding of the Fraser guidelines.

Are services caring at this hospital?

Services at MSI Maidstone were very process centric with staff showing limited empathy for how the patients might be feeling. Support from a partner, friend or parent was discouraged and accompanying supporters were asked to leave the premises whilst the patients were being treated.

Staff sometimes failed to consider patient’s privacy and walked into the the theatre whilst procedures were taking place.

There were complaints about staff being abrupt and blunt towards patients. However, there was good feedback from local surveys that showed individual staff were kind in their approach to individual patients.

Are services responsive at this hospital?

Services were planned and delivered in a way that met the needs of the population. The importance of flexibility, choice and continuity of care was reflected in the services provided both for private and NHS patients.

Patient flow through the centre was managed, although waiting areas could be very crowded at times.

Are services well led at this hospital?

Staff told us they did not feel valued by the organisation although they found the manager on site supportive and approachable. Corporate support was not recognised and staff felt they did not get a response if they tried to seek advice from regional managers.

Whilst Marie Stopes International provided the Maidstone centre with an Integrated Governance Framework in line with the NHS governance agenda and the CQC Essential Standards of Quality and Safety, there were gaps between the governance process at corporate and location level in communication and engagement which should be addressed to ensure evidence based care can be demonstrated at all times.

There was no robust system to ensure action plans were completed, reviewed and audited to improve patient safety and quality of care. We saw several examples of where concerns were identified by the infection prevention and control lead or nominated individual but which had not led to sustained improvement through robust action.

Effective risk management arrangements were not 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.

Staff were able to talk to us about some areas they considered high risk but had not done anything to try and bring about changes. Staff voiced concerns about KPIs, workloads, staffing and management support, facilities and training but did not take ownership for bringing about the necessary improvements.

Staff were not fully aware of the rationale behind a recent practice change for simultaneous administration of the medicines used to effect a medical abortion. There was no evidence based information on site to show this practice was recognised, benchmarked or systems put in place for effective measurement of patient for outcomes.

The culture was viewed as being top down and corporately led. We found that the staff felt there was little point in voicing concerns or suggesting improvements as they would not be acted upon.

Both patients and staff were encouraged to provide feedback on services provided. Staff contributions and performance were recognised corporately and celebrated which is good practice.

We regulate termination of pregnancy, but we do not currently have a legal duty to rate them when they are provided as a single specialty service. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

However, we also found the following issues that the service provider needs to improve:

Importantly, the provider must:

  • The provider must ensure that risks to patients are identified, assessed and monitored consistently throughout the treatment and recovery period, and that action plans in assessments and care plans are updated and contain enough detail to enable staff to reduce those risks effectively.
  • The provider must take prompt action to address a number of significant concerns identified during the inspection in relation to safeguarding, incident recording and reporting, and the governance of the service.
  • The provider must enable all staff to complete training that is necessary for them to fulfil their roles.
  • The provider must ensure staffing levels and skills mixes reflect patient needs.
  • The provider must ensure that consent is given and recorded in accordance with national guidance. This includes ensuring that the staff recording consent are able to discuss the individual patient’s risks of the procedures and the full range of options available to them.
  • The provider must display the Secretary of State's approval to carry out abortions.
  • The provider must ensure that staff follow MSI Infection Prevention and Control Policies in regards to hand hygiene, staff dress code, decontamination of equipment and premises and preparation of the patient prior to surgery.
  • The provider must ensure that staff adhere to MSI medicines management and national guidance on the safe management of medicines.
  • The provider must ensure there is appropriate clinical leadership at the centre with clear lines of accountability.
  • The provider must review the safe use of sedation medication and practice of individual doctors to reduce the risk of harm involving oversedation.
  • The provider must ensure that the care pathways consider the specific needs of children and other emotionally vulnerable patients attending the clinic.
  • Statutory Notifications must be submitted to the Commission as required by regulation.

Action the centre SHOULD take to improve;

  • Staff should have regular appraisals to establish continual professional development requirements to ensure staff have the right skills to perform their job role.
  • The provider should have specific written information in the waiting areas regarding key risks to patients such as domestic abuse, the risk of sexual exploitation, access to support groups and contact numbers if at risk.

Due to the number of concerns arising from the inspection of this and other MSI locations, we inspected the governance systems at the MSI corporate (provider) level in late July and August 2016. We identified serious concerns and MSI undertook the immediate voluntary suspension of the following services as of 19 August 2016 across its locations, where applicable:

  • Suspension of the termination of pregnancy for children and young people aged under 18 and those aged 18 and over who are vulnerable, to include those with a learning disability
  • Suspension of all terminations using general anaesthesia or conscious sedation
  • Suspension of all surgical terminations at the Norwich Centre

MSI responded to the most serious patient safety concerns we raised and was able to lift the restrictions on the provision of its termination of pregnancy services at this location on 7 October 2016.

CQC has also undertaken enforcement action for breaches of the following regulations, which are relevant to this location.Regulation 11 ConsentRegulation 12 Care and treatment must be provided in a safe way for service users.Regulation 13 Service users must be protected from abuse and improper treatment in accordance with this regulation.Regulation 17 Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part. (Good governance)Regulation 20 of the Care Quality Commission (Registration) Regulations 2009.

CQC is actively monitoring compliance with the above enforcement action taken in order to ensure that services are operated in a manner, which protects patients from abuse and avoidable harm.

Professor Sir Mike Richards

Chief Inspector of Hospitals

16 January 2014

During a routine inspection

We reviewed patient records and found that people's consent had been sought in advance of them receiving any treatment. People we spoke with confirmed that all of their treatment options, including any risks, had been discussed with them before they were asked for their consent.

People could be treated on the NHS or privately and could be referred by their GP or self-refer. The service operated a 24-hour, 365 days-a-year helpline for people wishing to discuss their needs or seek advice. People told us that they had been given appointments very quickly after requesting one. One person said: 'It took the stress off-being able to come in so quick'.We saw that there was a wide variety of information available to people attending the service for consultations or treatment. A counselling service was also available at any time during or after treatment.

We found the service to be clean and hygienic and saw that there were appropriate processes in place to assess and maintain the quality of cleaning. Staff had received up-to-date training in infection prevention and control.

Medicines were stored safely and recorded effectively by the service. There were policies in place about the management of medicines and staff had signed to state that they had read and understood the protocols.

The service had proactively sought the views of people and staff for the purpose of making any necessary improvements. Regular, routine audits had taken place and were used to identify any areas in which remedial action was needed. Staff training was recorded, monitored and updated to ensure that people were received care and treatment from staff that were trained to provide it.

7 February 2013

During a routine inspection

We previously carried out a visit to the service on 21 March 2012. The review was part of a targeted inspection programme to services that provided the regulated activity of terminations of pregnancy. The focus of our visit was to assess the use of the forms that were used to certify the grounds under which a termination of pregnancy may lawfully take place. We checked the provider's records and looked at medical records relating to termination of pregnancy services provided. We found that the registered provider met the part of the regulation which was the subject of this review in relation to the maintenance of HSA1 forms.

On the day of this visit, we were not able to speak directly with people using the service. We looked at feedback which the service had received from people who had completed a survey about their experiences of using the service. Feedback from people who used the service showed that overall satisfaction was excellent or very good. Services were provided by trained and competent staff who showed empathy and care for clients. Safeguarding procedures were in place and safeguarding concerns were documented and followed-up. There were systems in place for monitoring the quality and safety of services provided to people. Systems for monitoring risks to people and for reviewing adverse incidents were in place. Where improvements to services had been required, these had been made.

21 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.