BPAS - Nottingham West

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

The service was safe. Staff assessed individual and environmental risks and took actions to reduce them. Risks were managed positively and did not restrict patients lifestyle choices unnecessarily. The service had procedures to protect people from potential abuse and unsafe care. There were enough staff with the necessary skills, experience and qualifications to meet patients’ needs and preferences. Patients received their medication on time and in a safe way. The environment was safe and well maintained. Good levels of infection prevention and control were maintained throughout the service.

However, we noted that there were items missing from the resuscitation trolley for example there were no ligature cutters or clock in the trolley. The drawer numbers did not match the number on the audit tool, and the scissors were in the wrong drawer.

At our last assessment we rated this key question good. At this assessment the rating has remained the same. This meant patients were safe and protected from avoidable harm.

This service scored 75 (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 proactive and positive culture of safety, based on openness, transparency and honesty. Staff actively listened to concerns about safety and fully investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. For example, incidents of retained products of conception were always reported as an incident and any learning cascaded to staff.

Incidents were reported through the electronic reporting system which all staff had access to.

Staff received feedback from investigations of incidents. Learning was shared through team meetings and the monthly newsletter.

Leaders and staff were fully aware of their responsibilities for reporting incidents and accidents. These were reported in line with the policy of the service.

Staff said they felt they could raise incidents and concerns with both their colleagues and leaders without fear, and there was a positive culture within the service.

Data showed for the period September 2024 to September 2025, there were no serious incidents, or patient safety Incident Investigations declared for the service.

There was a standard operating procedure that provided guidance to the requirements of duty of candour, and all senior staff were knowledgeable about this.

Policies included the action staff should take for female genital mutilation and awareness of child sexual exploitation.

Staff had access to clear and documented systems to ensure patient risks were identified and managed. These systems supported the safe delivery of care to patients.

The service worked with patients and those close to them to establish, maintain safe, effective treatment and care to eliminate risks and ensure continuity of care.

With the patients’ consent, electronic records and images could be shared with other healthcare providers.

Discharge letters present in the patients records we reviewed, included that contraception had been discussed with patients choosing to seek further support or treatment from the GP.

The service had a policy for when a patient would need to be transferred to hospital in case of an emergency. The policy named the hospital and was detailed and up to date.

Staff were also aware of the policy and the procedure to follow in the event of a patient needing emergency transfer to an NHS service supported by clinical guidelines on the management of major haemorrhage.

All cases of continuing teenage pregnancy were referred to the community midwife teenage pregnancy team.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

Staff knew how to identify adults and children at risk of, suffering or likely to suffer significant harm and worked with other agencies to protect them. Staff worked with police when needed to support patients’ who were victims of crime.

During consultations, all patients were seen on their own for part of the process. This meant patients had the opportunity to disclose any safeguarding issues they may be experiencing in a safe environment.

Staff completed a safeguarding risk assessment for all patients under the age of 18 to identify children or young people at risk of, or suffering, significant harm. If a child or young person was identified as being on a child protection plan the service liaised with the general practitioner, social worker and all other relevant agencies including the police.

Under the Sexual Offences Act 2003 a child under 13 years is not capable of consenting to sexual activity, should a child under that age become pregnant, this is classed as statutory rape In line with their safeguarding policy the service can provide termination of pregnancy at this location for children.

All staff received training specific for their role on how to recognise and report abuse. At the time of our inspection, 90% of staff had attended level 3 safeguarding children and adults and 100% of staff had attended level 2 safeguarding children and adults, against the service target of 100%. Refresher training was undertaken every two years.

A designated member of staff was responsible for managing safeguarding concerns.

Safeguarding concerns and issues could be escalated to the organisations lead nurse for safeguarding, the safeguarding lead group or the relevant local safeguarding team depending on the nature and urgency of the concern. Collaborative work took place between local safeguarding services and the registered manager.

Safeguarding concerns were discussed in daily safety huddles. Staff kept a safeguarding log that contained significant information such as the date, if a safeguarding referral had been completed and what advice was given. The log contained details and outcomes of concerns; for example, if the police had been contacted.

The service had a range of policies to support staff in managing safeguarding issues including local child protection procedures, domestic abuse and protection of vulnerable adults. Policies included the action staff should take if they observed that female genital mutilation had taken place on a patient.

The service protected patients from the risk of abuse and avoidable harm. Patients were risk assessed to ensure they were suitable for treatment at the service and staff monitored them appropriately during their stay.

Pre-operative assessments were carried out in line with national guidance and all forms were completed. Initial consultations were documented electronically, and forms were completed. In order to meet legislation requirements, a HSA1 (Health Service Administration) form was completed by 2 doctors before medication to terminate a pregnancy was dispensed to women or surgical treatment carried out. Records showed HSA1 forms were completed to demonstrate legislation was met. Staff also completed HSA4 forms to notify the government about each early medical termination which took place. Completion of both forms was monitored by the service weekly.

Staff used recognised tools to improve the detection and response to clinical deterioration in patients as a key element of patient safety and improving patient outcomes. Staff used a modified Termination Early Warning Score (TEWS) (a system used to identify deteriorating patients) which included blood loss and was appropriate for both women and girls under 18 years of age. The TEWS scoring tool was used alongside nurses and midwifes’ professional judgement. Records showed staff had identified deteriorating patients and treated them accordingly.

There were processes to respond to medical emergencies. There was a formal process to transfer patients to hospital which was jointly monitored and reviewed by the service and hospital.

Staff used a modified surgical safety checklist based on the World Health Organization (WHO) 5 steps to safer surgery checklist (a tool designed to improve the safety of surgical procedures) when undertaking all surgical terminations. We observed surgical staff completing the checklist at the time of surgery. The service audited completion of the checklist.

Non-clinical staff were trained in basic life support, and all clinical staff were fully trained in immediate life support including resuscitation.

There was a process to check the identity of patients which staff were knowledgeable about. Reception staff were observed checking patients personal details when they entered the clinic and providing a further check they had the correct patient record.

The service provided procedures for both private and NHS patients. NHS patients were referred from the patients GP or could self-refer by the service website or by phone. Privately funded patients could also self-refer.

Staff completed risk assessments for each patient during the pre-assessment consultation and throughout their care and treatment. Comprehensive risk assessments were completed for each person requesting treatment. Risk factors included a number of various conditions, for example, high body mass index (BMI), elevated blood pressure and mental health issues.

Patients were also given a ‘My BPAS’ guide which described in detail the termination the patient was going to undertake, the effects and what actions to take if there was a problem after the abortion. For example, heavy and prolonged bleeding and how to contact the BPAS advice line.

A policy was in place to support staff managing the deteriorating or septic patient which included the use of a modified early warning system, communication using the situation, background, assessment and recommendations (SBAR) method and clear escalation guidance. The UK Sepsis Trust, sepsis screening and action tool was also included in the surgical procedure documentation.

Patients were advised to call the aftercare line if they had certain specific symptoms including fever. Staff manning the aftercare line used the sepsis screening and action tool and escalated patients to urgent or emergency health services as appropriate

We reviewed 5 risk assessments and saw they were all completed correctly.

Patients were given extended appointment times dependant on their age and safeguarding risk which allowed staff to adapt patients consultation and treatment dependent on their individual needs.

Staff had clear guidance to follow should a patient’s condition deteriorate while they were undergoing a termination of pregnancy procedure.

Patients told us staff were supportive throughout the process, and they felt their risks were managed well and their concerns listened to.

Patients we spoke with during our inspection, described regular and open conversations concerning their termination outcomes. They told us they felt involved in the process and that staff listened to any concerns they had and took them seriously.

We observed that staff made sure patients understood the treatment that was being provided.

The design of the environment followed national guidance. Facilities, equipment and technology were well-maintained and consistently supported staff to deliver safe and effective care.

The theatre room where surgery took place was spacious, which allowed for staff to undertake their work without hindrance and for partners to attend the termination of pregnancy procedure should the patient request for them to do so.

Electrical equipment was regularly tested. Routine servicing of equipment was planned in advance to avoid disruption.

Clinical waste was managed appropriately.

We checked single use items in consulting rooms, and all were stored appropriately and were in date.

The service had both a resuscitation and a haemorrhage trolley to be used in emergency.

A tamper seal was present and intact which meant that staff were assured that nothing had been used since the last time that they were checked.

The tamper seal on the trolley was broken once a month for a full audit of equipment. We checked the resuscitation trolley and found all equipment was in date.

The service told us they undertook a full audit of all equipment in the trolley drawers on a monthly basis, however, we noted there were a number of items missing, for example there were no ligature cutters or clock on the trolley which are required on all resuscitation trollies according to the resuscitation council. The drawer numbers did not match the number on the audit tool, and the scissors were in the wrong drawer. We immediately escalated these items to the manager in charge, who rectified them.

The service had enough nursing and medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed staffing levels and skill mix.

Care and treatment was undertaken by a team including a surgeon, registered nurses, midwives, client care co coordinators, receptionists and health care assistants. Staffing levels were reviewed daily.

All new members of staff underwent a structured and comprehensive induction training programme appropriate to their role.

There was a procedure to check that nurses and other health care professionals maintained their registration with their professional bodies.

The service had a mandatory training and competency framework; compliance was monitored through the service training database. All mandatory training and competencies were reviewed on a regular basis to ensure that they met current guidelines and procedures.

The service provided appropriate mandatory training for their staff, including manual handling, Health and Safety and Duty of Candour. Clinical staff mandatory training completion at the time of our inspection was 98.7% and clinical management at 100% against the service target of 100%.

Staff at all levels received regular appraisals, which provided them with development and career opportunities as well as their own wellbeing and safety was supported. At the time of our assessment 100% of staff had completed their yearly appraisal.

The service employed one consultant surgeon who worked one day per week to carry out surgical abortions. Cover was available from other BPAS clinics for when the surgeon was on leave.

Staff working within the service told us staffing levels were appropriate for them to provide good patient care.

We observed staff were visible in all areas and did not appear to be hurried or rushed in their work . Staff communicated well with each other to respond promptly to patient’s needs.

We spoke with 7 patients who told us there always appeared to be enough staff to provide good care. One person told us “they are really good here and are never too busy if I have a question or I am worried about something.”

The service-controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment visibly clean.
All areas of the clinic were observed to be visibly clean and tidy, including the reception and waiting area. Staff were observed to be following the service’s ‘bare below the elbows’ protocol. Hand gels were readily available in all areas of the clinic.
Staff followed infection control principles including the use of personal protective equipment (PPE), appropriately.
During our inspection, we observed 4 surgical terminations being undertaken in the theatre room. The correct equipment was used appropriately during each procedure. Infection prevention control (IPC) procedures were undertaken correctly during all the clinical procedures, and all sharps were correctly disposed of in the sharps bin.
Pregnancy remains were stored separately from other clinical waste before being sent for incineration the day after surgery.
We saw staff regularly utilise the alcohol hand rubs in accordance with the World Health Organisation’s (WHO) ‘5 Moments for Hand Hygiene’. These guidelines are for all staff working within healthcare environments and define the key moments when staff should be performing hand hygiene in order to reduce risk of cross contamination between patients.
We observed equipment had ‘Green I am clean’ stickers on once they had been cleaned and were ready for use.
Staff undertook IPC audits across the department for infection control, hand hygiene and uniforms. For the period April 2024 to March 2025 data showed 100% compliance for hand hygiene and uniforms and 97% compliance for infection control.
Infection control was part of mandatory training for all clinical staff.

The service used systems and procedures to safely prescribe, administer, record and store medicines. Staff completed regular checks of medicines in line with the service guidance.

Staff gave patients detailed information about the medicines used for early medical terminations during consultations. Medicines needed for an early medical termination were given as part of a two-stage process.

During their consultation, patients who were suitable were provided with all the medication required for an early medical abortion. If they wished, they could take the first medication in the clinic and complete the treatment at home. Alternatively, they could take both stages of medication with them and administer at home.

During the consultations we observed staff describing to patients how and when the medicines should be taken and checking the patients understanding.

All medications we checked as part of our inspection and were found to be in date and correctly stored.

Patients’ requirement for pain relief were met appropriately before, during and after their procedure. Preventive pain relief was offered before both medical and surgical terminations. A pain assessment tool was used for both medical and surgical patients. Patients told us staff were good at checking with them to ensure they received the right pain relief when they needed it.

The service used conscious sedation during surgical terminations, this helped relax the patient and reduced anxiety and pain during the procedure. Oxygen can be used to maintain blood oxygen saturation levels and to flush out sedative gases at the end of a procedure.