Archived: NUPAS Aylesbury

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

Well led: 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 the service. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated and person-centred.

This is the first assessment for this service. This key question has been rated good. This meant the service was consistently managed and well-led.

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.

We scored the service as 3. The service had a shared vision, strategy and culture. The managerial team fully supported the vision and strategy of the service.

All staff we spoke with were aware of the NUPAS values and mission statement. The values included; the importance of staff and how they would be supported, the passion and care of staff, that women would always be supported in their right to choose and a focus on being open and honest and providing safe care. Appraisal discussions were linked to these so staff could evidence they were ‘living the values’. The values were also a core focus of corporate induction days, and the services chief executive officer attended a values session with each new cohort.

Staff feedback was reviewed twice a year via the staff survey. The service was waiting for head office to publish the analysis of the most recent results.

Staff advised us there were opportunities for clinic staff to attend committee meetings to improve their understanding of systems and processes.

We scored the service as 3. All leaders embodied the culture and values of their workforce and organisation.

Managers ensured they were appropriately registered, that the service had an up-to-date certificate from the Secretary of State and the Department of Health. Managers also ensured they were compliant with CQC registration standards.

Managers understood their responsibility in reporting notifiable incidents. The clinic manager was able to access peer support with other NUPAS managers. At the time of inspection, they met informally, however, the service was developing a set of objectives, and formal agenda for these meetings.

The head of operations directly line managed the clinic managers and ensured they had oversight of operational performance dashboards, had weekly informal catch up calls that included discussions around competencies and attended monthly floor to board safety briefings.

Staff advised us they felt able to discuss any issues or concerns with the entirety of their senior leadership team, including the chief executive.

We scored the service as 3. Staff felt that they could speak up, and that action would be taken.

The service had a ‘You Said, We Did’ page, where staff received updates regarding how managers had implemented change following feedback.

All staff we spoke with said they felt empowered to speak up if they had a concern. Staff advised us they were confident action would be taken if an issue was raised.

All staff we spoke with knew how to access the service’s Freedom to Speak Up Champion. We were advised the clinic also had two guardians.

We scored the service as 3. The service valued diversity in their workforce, and there was an inclusive and fair culture.

Everyone we spoke with advised us they enjoyed working for the service and that due to the nature of the role, staff saw it as a vocation rather than just a job. All staff were very passionate about providing safe care and were very open and non-judgemental of women’s choices and lifestyle.

The staff and managers were proud of the team they had built. Staff advised us it was a strong group, that worked well together over the short amount of time the service had been operating.

One member of staff advised us they had initially struggled with the workload, had raised their concerns and been allocated a deputy.

We scored the service as 3. All areas of the service had clear responsibilities, roles, systems of accountability and evidenced good governance.

The clinical director and operations and projects director maintained oversight of operational governance, they were supported by the head of operations. The head of operations oversaw the regional managers. The regional manager was the registered manager of all clinics within their patch. For NUPAS Aylesbury, the patch included; Oxfordshire, Buckinghamshire, Berkshire and Frimley.

Offsite NUPAS services, for example the booking and counselling teams, were managed by the operations and projects director.

Clinical team meetings were co-chaired and managed by the medical director and clinical director and included, the pharmacy team, head of nursing and safeguarding lead and quality assurance lead.

The clinic manager met with the senior leadership team monthly to review incidents, complaints and performance data. Performance data included benchmarking against other sites. This information was presented to the clinical leadership team, who also met monthly to ensure policies and processes were ratified and up to date. Reports from these meetings were presented at board.

Clinic managers reviewed local risk registers at bi-monthly team meetings. Clinics closed whilst these meeting took place ensure all staff could attend. Managers and staff were aware of the biggest risk at the locations where they worked, and we observed action plans that included review dates and had an accountable person logged to review and mitigate each risk.

However, we found there was a lack of oversight of the risks associated with the location of the service and women attending.

We scored the service as 3. The service understood their duty to collaborate and work in partnership, so services work seamlessly. Staff shared information and learning with partners and collaborated for improvement.

Managers worked closely with the local NHS early pregnancy units to improve their understanding of pregnancy scans. The service had a plan for educating staff at trusts on the differences between retained products and pregnancy detritus. This was in response to an increase in reported incidents where further investigation found that these were being reported as retained products, when they would have been removed from the body naturally when the woman had her next period.

We scored the service as 3. The service was focused on continuous learning and improvement.

Staff at the service developed a call bell system to notify them when women were ready to move from one area of the service to another. Each area had a distinctive ring for the admission room, treatment room/surgical suite and recovery. The service also had a fourth bell for emergencies, staff from NUPAS and the GP practice had a formal agreement to support each other in the event the emergency call bell was rung.