BPAS Healthcare

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

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. People with protected characteristics felt supported. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

We rated this key question good. This meant the service was well-led and had good governance structures that were used to improve the performance of the service and ensured the delivery of safe care and treatment.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff told us the organisation vision and strategy had recently been updated. They said details of the changes had been communicated through a virtual all staff conference. Posters outlining the new vision, the strategy for achieving the vision, and the underpinning values were visible in staff areas.

Staff and leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service. Staff told us the culture was focussed on providing a high standard of care for women and also for each other. One person told us, “Everyone genuinely cares about everyone, it's nice to have that at work and not just coming to work and doing your job.”

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.

The service had a clear leadership structure, so staff knew who to approach for support.

Staff at all levels told us their leaders were visible and approachable. Staff spoke favourably about the online chat system they used. They told us this helped them to feel connected to their peers, managers, and to leaders within the wider organisation.

Leaders had the skills, knowledge, experience to run the service. They told us they were provided with opportunities to develop their leadership skills.

Staff felt respected, supported and valued. They were encouraged to develop their skills and were given developmental opportunities. For example, leaders told us when staff identified they were interested in developing into a leadership role they were provided with opportunities to develop these skills. Staff also told us they could be seconded into a more specialist role if they wanted development opportunities.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The staff we spoke with told us they worked in a culture where speaking up was encouraged and valued. They knew about the freedom to speak up guardian and how to contact them should the need arise. Freedom to Speak Up Guardians have an independent role within an organisation to listen to, support, and guide workers who feel they cannot use formal channels to raise concerns about patient care or other organisational issues.

The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Leaders worked to create an inclusive working environment. Staff were encouraged to speak to managers about any reasonable adjustments they needed to improve their working lives. The service also offered staff flexible working hours and job sharing to meet their needs.

The organisation had an annual people survey so staff could share their views about working for the organisation. The results from the 2024 survey showed that most staff agreed all staff were treated fairly regardless of differences such as background, ethnicity, religion/beliefs, gender, age, disability, marital status, pregnancy/maternity, gender reassignment, or sexual orientation. The results also showed people felt that they could be themselves at work and they didn't need to hide or minimise aspects of their physical, cultural, spiritual, emotional self or background while at work. Meetings were held with staff to explore what could be done differently to improve how they felt about working for the organisation.

The organisation had a range of networks to promote visible representation and acceptance of difference within the workforce, and safe space where people could access advice and information. The networks included, a disability equality network, a race equality network, a neurodiversity network, a parent and carers network, and a lesbian, gay, bisexual, transgender, queer or questioning network.

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

The telemedical service had daily meetings to review and manage incidents.

The service had a ‘floor to board’ approach to communication. All staff were invited to regular virtual all colleague conference calls led by board members. This enabled important information to be shared with staff at the same time. These meetings had protected time for staff to ask questions of the board and to share their concerns with them. There were also local meetings, which included task and finish groups and champions groups, that met regularly. Issues and concerns from these meetings were taken up to the sub committees that escalated risk to the organisation’s executive leaders. The sub committees also fed into the monthly quality risk group meetings which was then raised with the quarterly governance committee. Information discussed at these meetings fed directly into the board meetings. Information could also be shared back to staff using these lines of communication.

The service had a risk register. Risks were regularly reviewed in governance meetings to monitor actions identified to reduce risk. The biggest risk was a data breach that had affected 16 patients across the county in early 2025. Risk was mitigated by a temporary work round on the electronic patient record (EPR) system to ensure information was only shared with women’s GP if they had given explicit consent for this while a permanent change to the EPR was being organised.

In order to meet the requirements of the Abortion Act 1967 and 1990, a HSA1 form was completed by 2 doctors before medication to terminate a pregnancy was dispensed to women. Completed HSA1 forms demonstrate the legality of an abortion as set out in the Act. Staff also completed HSA4 forms to notify the government about each early medical termination that took place in a women’s home.

Managers had quarterly meetings to look at patient feedback and discuss themes and trends to explore how they could improve the experience of women using the service. They shared this information with staff and encouraged them to use innovation to design and develop service improvements through the quality improvement board.

Leaders had oversight of the audits completed for clinic so they could ensure any actions required to improve compliance were completed. Compliance with audits undertaken in March 2025 included patient records 98%, consent 100% and HSA1 forms 100%.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Staff share information and learning with partners and collaborate for improvement.

Staff worked in partnership with social care teams, domestic abuse services, and other services to ensure women and their children were safeguarded from harm.

Managers and representatives from the wider organisation had regular meetings with commissioners to discuss contract management and look at performance against key performance indicators.

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 people. Staff actively contribute to safe, effective practice and research.

Staff told us they were encouraged to share their thoughts about improving ways of working.

At the time of the inspection, the suitability tool used by the organisation was under review. This review aimed to ensure the tool was evidence-based and supported the delivery of high-quality, safe care, particularly in managing complex cases. The tool was used by staff to help determine whether a woman had a medical condition or was taking medicines that may be contraindicated with medical abortion treatment. The review process was intended to align the tool’s recommendations more closely with clinical decision-making, ensuring consistency, safety, and appropriateness of care.

The organisation had a quality improvement board that met regularly. Each location had a team member that volunteered to sit on the board although suggestions about improvements could come from any member of staff. When speaking about staff involvement in quality improvement a senior leader told us, “Staff are very enthusiastic and are willing to get involved. Coming here has been a breath of fresh air.”

The topics covered by the quality improvement board also reflected the outcomes of audits and key performance indicators (KPIs) that required improvement to increase compliance.

The organisation had an academic research and ethics committee. There were 13 different studies ongoing in 2025, for example reproductive and mental health care of ethnic minority and migrant women in England. Staff were actively encouraged to become involved with the research studies and learning from the outcome of research was shared across the organisation to improve patient outcomes. For example, the study discussed above about pain outcomes.

Staff told us the growth of the telemedical hubs developed out of a need for innovation to ensure women’s access to abortion treatment during the COVID-19 pandemic. They said the service continues to be developed on the foundations of this innovative approach.

A senior leader told us their aim was to deliver a gold standard of care which could be achieved through an increase in practitioner led care. They had a focus on what the organisation needed to do to deliver that, and ultimately, they thought this could be achieved, in part, through an increase in development opportunities for staff. The outcome of this would mean they could introduce more support for existing services within the wider community to create a wider range of options. Enabling them to expand their delivery of safe care to meet the needs of women requiring termination of pregnancy, sexual health screening, and people requiring contraception.