Archived: NUPAS Aylesbury

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

Safe: We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that women were safe and protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated good.

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.

We scored the service as 3. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service used on online reporting system that was shared across all NUPAS locations. Staff told us it was an easy system to use. When the details of an incident were uploaded onto the system, an email alert was automatically sent the clinic manager and any appropriate head office leads, for example, safeguarding or the Infection Prevention and Control (IPC) leads for investigation. All incident investigation reports were reviewed by the NUPAS safety and risk committee, who reported to the board.

The service used the Patient Safety Incident Response Framework (PSIRF) to review incidents. This “sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety”.

Staff had access to updates and learning from incidents. Managers shared site specific updates verbally with individuals and teams during safety huddles and team meetings. General learning was available on the quarterly staff newsletter as well as on the intranet. Staff confirmed they had read and understood the contents.

Staff shared examples of learning from incidents both internally and externally. For example, another provider of termination of pregnancy services experienced an arson attack from protesters. In response to this, all staff had to complete refresher conflict resolution training, that had been updated to include dealing with protesters. The location of sharps bins, at all NUPAS sites was reviewed and risk assessed, following an incident where the bin was placed on a high shelf and there was a risk of it being overfilled, posing a sharps risk. Sharps incidents are accidental skin punctures by contaminated items (needles, scalpels, broken glass) in healthcare, posing risks of blood-borne infections.

Staff understood their role and responsibilities regarding duty of candour. Duty of candour is a legal and professional obligation for health and care services to be open and honest when something goes wrong.

We scored the service as 3. The service worked with women and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

NUPAS provided a ‘Pills by Post’ service. Women had to meet all the risk criteria reviewed during their initial consultation. If any question was met with doubt or did not meet the risk requirements, women attended a clinic for a scan before proceeding.

Women attended the clinic for scans at the earliest opportunity. Women whose gestation was within the limit for early medical abortion, were able to choose whether they had a medical or surgical termination, after which, women were offered a surgical termination. If staff had any questions or queries about what they found during a scan, they could access support and send scan photos to the services lead sonographer, based at head office. Staff advised us they received same day feedback.

Staff demonstrated the use of referral pathways, for example to identify an anomaly. If staff identified a ‘pregnancy of unknown location’ (when a positive pregnancy test is not matched by an ultrasound that can see a pregnancy in or outside the uterus. This can mean the pregnancy is too early to see, an early miscarriage has occurred, or it is an ectopic pregnancy) or there was unknown viability, the pathway advised referral to the early pregnancy clinics at the two local acute hospitals.

We scored the service as 2. The service worked with women and healthcare partners to improve women’s lives while protecting their right to live in safety. However, safeguarding information was not always analysed in order to ensure improvement.

The service monitored the number of women who returned for follow up appointments. Data from the service showed the uptake for follow ups was around 15%.

The service was unable to collate clinic specific data, however, NUPAS data for the whole of Berkshire, Oxfordshire, Buckinghamshire and Frimley for the 12 months prior showed a 38% termination repeat rate, which is less than the national average of 42%.

The service did not have a formal policy, process, or procedure in place to support women undergoing repeat terminations. Staff told us that the team reviewed each case on an individual basis to determine appropriate next steps. However, without a consistent framework, the actions taken could vary depending on which staff members were involved in the review, leading to a lack of standardisation in care and decision-making.

The number of women taking up Long-Acting Reversible Contraception (LARC) had decreased. However, since the assessment, managers implemented a number of actions to improve uptake. These include increased training for clinicians, extending the offer of post-abortion contraception from three months to six months, and ensuring that all staff received College of Sexual and Reproductive Healthcare (CSRH) contraception training. In addition, the service updated its contraception policy and staff competency frameworks, audited contraceptive discussions during the consultation process, and refreshed Family Planning Association links on its website.

However, staff knew who the services safeguarding lead was and how to access help if they had a query. Safeguarding topics were regularly discussed at team meetings and training sessions to improve understanding and best practice. Recent topics included domestic violence and trafficking. Staff received safeguarding training at the appropriate level in accordance with the Intercollegiate document. All nursing staff received regular safeguarding supervision, and the safeguarding lead organised monthly scenario training. Staff understood how to identify Female Genital Mutilation (FGM) as well as how to make a Police referral for FGM, rape and statutory rape.

Staff ensured that if a woman was escorted to an appointment, they had one to one time with the woman to ensure they were not coerced into treatment.

Posters stating women were entitled to a chaperone were located throughout the clinical area. We noted staff advised women they were entitled to a chaperone on each appointment observed.

Any women requesting treatment who was under 16 was required to have a face-to-face appointment at a clinic.

The service worked closely with a local charity that supported women who were pregnant whilst having other children already in care.

Staff were trained to the appropriate level of safeguarding training in accordance with intercollegiate guidance. The safeguarding adults and children’s policies were up to date, and included all appropriate information including various pathways for referral dependent on age, for example, under 13 year olds.

We scored the service as 3. The service worked with women to understand and manage risks. Staff provided care to meet women’s needs that was safe.

The service had a specialist placement policy for urgent referrals for women nearing 24 weeks of pregnancy. The policy stated staff would ensure women could receive treatment before the 24 week deadline, even if the treatment was with another provider.

We observed pre surgery appointments which included checks of; blood pressure, weight/height, rhesus status (rhesus status in pregnancy is determined by a blood test to see if a mother is positive or negative and is managed with injections of anti-D immunoglobulin) and a Venous Thromboembolism assessment (Venous Thromboembolism is a condition where a blood clot forms in a vein, which can be a deep vein thrombosis or a pulmonary embolism). Women’s medical histories were also reviewed to ensure all risks were mitigated.

On days when surgery took place, staff were clear about their roles and responsibilities in the event of an emergency. This was agreed during the morning safety huddle.

Staff completed a World Health Organization (WHO) Surgical Safety Checklist for all women on the surgical lists. The WHO Surgical Safety Checklist is a 19-item tool designed to improve communication and reduce surgical errors by ensuring critical steps are followed.

A box for managing a haemorrhage in an emergency was available. This contained all emergency equipment required if a woman started bleeding heavily, for example, anti-bleeding medicines.

Staff used standardised national assessments for monitoring deterioration, and were trained in recognising the signs and symptoms of deterioration, including sepsis and knew how to escalate and follow the transfer agreement to the local acute trust.

Staff had access to a defibrillator which was located within easy access of the clinic rooms in the event of an emergency. Staff tested equipment daily to ensure its efficacy.

Post termination, women were given details of the services 24-hour aftercare telephone line, we observed women were advised they could use the line for any query or concern, no matter how big or small.

Staff received Skills and Drills scenario training, including emergency transfers. Skills and drills refers to simulation-based training where healthcare staff practice clinical and teamwork scenarios in a safe environment, using realistic situations to improve communication, critical thinking, and technical skills for better safety and outcomes.

We scored the service as 3. The service ensured facilities supported the delivery of safe care.

The clinic rented several rooms located at the end of a corridor next to a fire exit. One room was used for medical terminations, including scanning on Fridays, on surgical days this was transformed into a recovery room. This was located opposite the dedicated surgical suite, medicine and consumable storage was located in a side room off the suite. A third room was used for admissions and there was a toilet next door.

The clinic was clean and clutter free, and the physical environment of clinical areas, including the surgical suite met Department of Health, Health Building Note 00-09 standards. Managers met regularly with senior staff at the onsite GP practice to ensure any environmental concerns were reviewed.

The GP practice was responsible for ensuring fire extinguishers were serviced, full and in date. Managers showed us copies of evacuation plans and worked with the GP practice to ensure all staff took part in evacuation practices twice a year.

The services equipment strategy group was responsible for ensuring the maintenance of equipment and reviewing any equipment related incidents. This team met quarterly and results of annual reports were presented at board.

Maintenance records, including Legionnaire water testing, equipment servicing and portable appliance testing were up to date. Business continuity plans included risk assessments, plans and mitigations for power outages and flooding.

We scored the service as 3. The service ensured there were enough qualified, skilled and experienced staff to keep women safe. Staff worked well together to provide safe care.

The manager used the NUPAS safe staffing policy to determine appropriate staffing numbers. If there was a vacancy, the manager sent a request to NUPAS human resources and finance teams for sign off on advertising vacancies. The service used the NHS screening tool for short listing. Interviews were managed centrally, including ensuring all employee safety checks were completed, for example Disclosure and Barring Service (DBS). DBS is a UK government body that checks a person's criminal record for employers. The clinic manager was notified of start dates when these checks were complete.

New staff were given a tailored induction that was a mix of corporate and local learning. New staff were required to complete all mandatory training before commencing clinical work. The clinic manager arranged one to one meetings with new starters weekly for their first month, then monthly until the end of their 6 month probation period. These meetings were used to discuss progress of competencies, training and any concerns or questions.

Mandatory training requirements were specific for each job role. Staff received allocated learning time in order to complete their training, staff and managers also had a weekly catch up where issues or concerns regarding training requirements could be discussed.

Mandatory training topics included; fire training, health and safety and infection prevention and control. The clinic manager maintained oversight of mandatory training completion rates. Twenty seven out of thirty topics had a staff completion rate of 100%. The remaining three, were in the high nineties, these staff were either off with long term sickness or maternity leave. Managers had plans in place to ensure staff were allocated time to complete these modules.

Documentation showed that all staff received an appraisal. Staff stated they were given time to prepare for appraisals, they were a meaningful opportunity to have honest conversations about areas for improvement, and a chance to discuss career progression. Appraisals were used as an opportunity to review staff objectives, including expanding staff competencies, for example, contraceptive training and prescribing. Staff stated that managers were always open to career development and supported them with funding, applications and allocating time to complete training.

Staff completed clinical passports, which recorded competencies for consultation, pre-operative care, contraception training and scanning courses. Staff said they received a lot of training from the provider and had lots of opportunities to develop skills. The lead sonographer ran a monthly lunch-and-learn session to improve scanning skills. Staff advised us they were supported to attend conferences.

The clinic manager was responsible for organising the staffing of the surgical list and clinic days. Staffing numbers and skill mix were based on the safe staffing policy. We viewed the services rota and noted that planned versus actual staffing numbers matched.

On surgical days, staff in the theatre included; the doctor surgeon, a nurse or midwife and health care assistant, there was also another nurse in recovery. This ensured that women received one to one care during treatment in accordance with best practice.

The NUPAS head office managed the rotas for doctors, who were contracted from the NHS to work at the service on a part time basis. Doctors were rotated to either work remotely to sign off HSA forms or lead onsite surgical lists. Clinics were notified of the doctors’ information and contact details for the next day’s clinic. The NUPAS head office allocated a responsible officer in case staff had any questions or queries regarding a signature or reasoning.

We scored the service as 3. The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading.

The onsite GP practice was responsible for general waste disposal and cleaning clinic rooms. NUPAS staff were responsible for cleaning all equipment, as well as the surgical suite pre and post-surgical lists. Staff with enhanced theatre infection prevention and control competency training supported surgical lists.

The service contracted a third party to dispose pregnancy remains. Whilst onsite, remains were stored in a freezer which had a weekly deep clean.

Cleaning charts located throughout the GP practice, were signed and dated. Staff completed a service specific daily checklist to ensure all areas of the service were clean before the clinic opened. There was an enhanced infection control checklist for the surgical suite.

We observed staff were bare below the elbows in accordance with national guidelines. Bare below the elbows requires healthcare staff to remove items from their forearms and elbows down to promote effective hand hygiene and reduce the spread of infection. Posters demonstrating effective hand hygiene practices were located above every sink.

There was sufficient personal protective equipment, for example aprons and gloves, in a range of sizes to ensure they fit appropriately in line with Health and Safety Executive guidelines.

We observed effective cleaning and use of covers on scanning probes, staff used stickers to indicate when equipment had been cleaned.

Managers used a range of tools and audits to ensure all areas of the service met infection control standards, we viewed 9 audits and noted they were detailed, covered expected areas and scored appropriately. Managers had action plans in place where improvements were required.

We scored the service as 3. The service made sure that medicines and treatments met women’s needs and preferences.

All medicines were ordered centrally at the NUPAS head office. Items were safely stored in locked cupboards in a lockable room. Only the manager and lead midwife had access to these areas. Staff monitored and recorded the temperature of all storage areas, including the fridge and freezer. Staff understood what range medicines and consumables should be stored, and described escalation processes, if the temperature went out of range. There was a back-up generator for the freezer if the site lost power.

The service was introducing sedation as an option for surgical termination of pregnancy. Whilst they were not being used at the time of inspection, we noted the controlled drug sedation medicines were stored appropriately and safely, that the service had an in-date controlled drug Home Office License, managers had completed risk assessments, staff had appropriate competencies and there were audits planned and ready for when sedation was operational.

The off-site doctors who signed the HSA form had responsibility for completing the prescription for early medical abortion medicines. The doctor leading surgical lists completed prescriptions for surgical preparation medicines. The onsite nurses had competencies for prescribing antibiotics and contraception’s.

The service had a contract with a third party for destruction of sharps bins. Sharps bins were labelled, dated and signed. Lids were securely fixed, and boxes were not filled beyond the recommended fill line.