BPAS - Middlesbrough

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 had an excellent learning culture. When women raised concerns about safety and ideas to improve, the primary response was always to learn and improve. There was strong awareness of the areas with the greatest safety risks. Solutions to risks were developed collaboratively. Managers investigated incidents thoroughly and the provider was open and transparent when things went wrong. Women were protected by a strong approach to safeguarding. Staff understood and managed risks. The facilities and equipment met the needs of women, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved women in planning any changes.

We rated this key question good. This meant women were safe and protected from avoidable harm. At our last assessment we rated this key question requires improvement. At that time the service was in breach of Regulation 12 (1) (2) (g) because medicines issued to clients by staff, known as TTO (to take out) packs, did not meet legal requirements for labelling. At this assessment the service was no longer in breach of Regulation 12 and the rating has changed to good.

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 and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

All staff knew what incidents to report, how to report them, and reported all incidents that they should report. The service used an electronic system to record incidents. There were no incidents of serious harm in the last 12 months and only 2 incidents of moderate harm at the Middlesbrough and South Shields clinics, and 1 at Newcastle. The moderate harm incidents all related to recognised complications including ectopic pregnancy and retained products of conception following medical or surgical abortion. The remainder resulted in low or no harm.

Staff followed a BPAS patient safety incident response plan, implemented by national senior leads, to prioritise incident reviews based on the potential for learning as well as their severity. Staff reviewed all incidents in twice-weekly divisional incident review meetings where opportunities for local, regional, and organisational learning were identified. Escalation to the Event Response Group (ERG) ensured the senior team would make a formal decision whether to initiate a structured learning response to an incident or group of incidents.

BPAS had adopted the Patient Safety Incident Response Framework (PSIRF) process in 2023. This is an 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 told us of positive changes to policy and practice in response to previous incidents. They said systems worked more effectively and there was very clear guidance on how to manage situations such as when a surgical list had to be cancelled.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. Staff wrote to patients following clinical complications as an additional welfare check.

Staff were debriefed and received support following any incident. Staff attended Sharing Education and Learning (SHELs) meetings and had regular learning opportunities to discuss locally reported incidents, as well as incidents that had occurred in other parts of the organisation. Learning points from the previous month’s incidents were shared on staff notice boards. The service produced a weekly newsletter that contained important information about incidents and policy updates.

Staff worked in small teams, each with a clinical lead. All staff we spoke with said they felt fully supported following incidents of all types and severity, including those involving aggression from patients or their partners. Staff told us they were encouraged and supported to raise concerns. They felt confident that they would always be treated with compassion and understanding, and would not be blamed, or treated negatively for reporting incidents and or raising concerns. They understood raising concerns helped to proactively identify and manage risks before safety events happen.

The service worked with women and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when women moved between different services.

Patients made initial contact through an online form or by telephoning the organisation’s national call centre. This initial contact was used to collect demographic data and important medical information and was entered into the organisation’s electronic patient record (EPR) system. Women could choose the day and time that they were called back for a telephone assessment, ultrasound scan, or face to face appointment as required.

Staff involved all the necessary healthcare services to ensure patients had continuity of safe care, both within the service and post-discharge or transfer. The service’s referral and admission processes ensured that all essential information about the patient was shared to determine if the patient’s needs could safely be met. The service had written transfer and escalation agreements with local NHS hospitals when the need arose. For example, when a patient had been found to have an ectopic pregnancy, staff telephoned the gynaecology ward and called for an ambulance to arrange a swift and efficient transfer, thus avoiding a wait in an emergency department, prolonged pain symptoms and the risk of a rupture. On another occasion a patient underwent a scan that showed their gestation was at the legal limit. Staff worked quickly with regional NHS staff and systems to ensure the patient received a further NHS dating scan and the most appropriate treatment available to them. Fortunately, the patient was able to complete their treatment within the legal limits at an NHS hospital.

Staff requested and received feedback from investigation of incidents, both internal and external to the service, including feedback following transfers of care to local NHS hospitals. BPAS shared incidents from other locations to ensure learning was shared and consistent. Staff met to discuss feedback and there was evidence that changes had been made because of feedback. For example, additional staff were recruited and deployed to ensure there were sufficient and timely post-treatment check appointments available. There was learning and action following an incident where a patient had telephoned the BPAS aftercare phone line for advice regarding pain, but the service had been unable to provide a face-to-face appointment in a timely way. The service had been able to refer patients to other clinics and for NHS treatment when gestation was over BPAS limits.

The service worked with women and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving women’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. The registered manager was the safeguarding lead for the service. Staff frequently dealt with complex, high-risk safeguarding cases and any individual could arrange a focus group with colleagues and the regional safeguarding lead who provided training, debriefs and feedback. BPAS had a national safeguarding lead responsible for policy and processes and to provide information and support to staff. This meant a named safeguarding professional was always contactable whenever the service was operational.

Staff working from satellite clinics had on-demand, digital or telephone access to safeguarding support and escalation through the BPAS safeguarding team. This supplemented local relationships with local police, NHS safeguarding teams, and local authority staff.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act (2010). Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff told us of incidents where they had done this and how they had worked with authorities and other services to ensure good and safe outcomes. On one occasion, clerical staff had followed the safeguarding procedure with a good outcome when they believed a small child had been left alone at home.

Staff followed safe procedures for children visiting or using the service. They ensured that children who had accompanied a family to the service were to be supervised by an accompanying adult. Staff followed policy to follow up a concern when they believed a child was at risk at home.

Across both BPAS sites, 97% of staff had completed safeguarding training to level 3 for adults and children. The treatment unit manager was also trained to Safeguarding level 3.

Patients of all ages were given the chance to meet staff alone for part of their appointment to ensure they felt safe. Patients accessing the service under the age of 18 were asked additional safeguarding questions. The electronic record system required all fields regarding this to be completed.

The service worked with women to understand and manage risks by thinking holistically. Staff provided care to meet women’s needs that was safe, supportive and enabled women to do the things that mattered to them.

Staff communicated with women so that they understood their care and treatment, including finding effective ways to communicate with women with communication difficulties. They had access to an interpreting service and were able to have patient information translated into other languages, this could be requested through the service when booking an appointment. Most patients used the BPAS telephone service as a first point of contact and for counselling prior to attending a clinic appointment. Staff told us they had also accepted patients who walked in and staff supported them to access the telephone service. Staff could provide information in different languages. Details of patient care and choices, and what to expect were provided in paper booklets or electronically.

Staff enabled patients to give feedback on the service they received and monitored responses. Staff were proactive in identifying and sharing learning following patient feedback.

Staff enabled patients to make advance decisions, to change their mind at any time about their chosen method, timing and location of their treatment and to allow patients sufficient time to do so. Staff ensured that patients could access further counselling, before or after treatment, if required.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service ensured equipment was well maintained and serviced appropriately. Electrical equipment had been PAT tested. Equipment, including theatre equipment, was used as intended by manufacturer guidelines.

The building had the correct fire exits and held fire evacuation exercises. The service displayed their up to date fire safety reports.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The previous inspection in April 2022 found there were insufficient staff to offer cover arrangements in the event of staff absence potentially delaying treatment times for women. At this assessment we found managers had calculated the number and grade of nurses and midwives required and the registered manager could adjust staffing levels daily to take account of case mix and clinic activity. There had been additional nurse and midwife recruitment to increase the joint staff to a team of 10, and staff worked flexibly between clinics when necessary.

The service did not use agency or bank nursing staff and there were no vacancies.

Staff working in satellite sites followed the same systems and processes for patient care, the same support systems, and liaised with the same external bodies as those in the Middlesbrough clinic. The lead nurse supported all clinical staff and checked competence and compliance met BPAS requirements across all sites. The treatment unit manager also carried out their role in the same way and visited all sites regularly. Staff completed peer reviews and shared good practice.

Staff told us they were encouraged and supported to progress to lead roles and to follow alternative career paths. New staff completed a comprehensive induction programme that included skills and competency training and assessment. One midwife was working in a supernumerary role because they had almost completed their full BPAS competency framework. This allowed other staff more time to carry out advanced skills and for the newer team member to shadow colleagues and complete competencies quickly.

Managers provided new staff with appropriate induction and opportunities to complete a standard competency framework.

Managers provided all staff with supervision (meetings to discuss care management, safeguarding cases and to reflect on and learn from practice, and for personal support, professional development, and appraisal of their work performance.

Managers ensured that staff had access to regular team meetings. They moved the venue for team meetings between clinics so all staff could attend, and this reduced travelling distances for alternate teams.

All staff had had an appraisal in the last 12 months. Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. One midwife had recently completed scanning competencies.

Managers ensured that staff received the necessary specialist training for their roles. They had the tools to deal with poor staff performance promptly and effectively.

There was adequate medical cover provided remotely. There were sufficient BPAS surgeons to carry out planned surgical abortions. At the last inspection we found there was no contingency for unplanned absence. There were no additional medical staff and the service had added this concern to their risk register. However, BPAS had implemented a new policy to guide staff in such an event. Staff told us the policy provided a clear process, along with involvement and support of BPAS senior leaders in decision making to ensure patients were provided with suitable and timely alternative treatments.

Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the patient group using the service.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained most equipment well and kept it clean. ‘Clean’ stickers were visible and in date. All clinical areas were clean, had required furnishings and were well-maintained. Cleaning records were up to date and demonstrated all areas were cleaned regularly. We observed staff adhered to infection control principles, including handwashing.

Staff had completed infection prevention and control (IPC) audits and results were displayed for the 12 months previous to this assessment. Compliance for IPC, hand hygiene, uniform standards, and cleanliness all showed between 96% and 100% compliance for all 3 sites. However, audits carried out by IPC Specialist Practitioners at Middlesbrough in April 2025 showed compliance for hand hygiene was 82%. General cleanliness at Newcastle reached only 70%. in October 2024. These results had not met the BPAS target of 95%. The cleaning team at Newcastle were provided with additional information on cleaning standards and the following audit results were all 100%. All staff had attended training and reports showed actions were completed to drive improvement.

There was a utility room accessed from the theatre. Staff had asked for it to be divided in two to provide separate clean and dirty rooms but this change had been denied as being too large an expense. However, staff arranged the room into clean and dirty areas and ensured there was no cross-contamination of supplies or waste.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved women in planning, including when changes happened.

Staff followed good practice and national guidelines in medicines management. Medicines were all correctly labelled following new BPAS medicines policy and processes and to meet legal requirements.

Staff stored and managed all medicines in line with the provider’s policy. Medicines including controlled drugs (CD’s) were stored securely and appropriate checks were in place in line with the provider’s policy.

Staff followed current national practice and guidance to check patients had the correct medicines. Policies and procedures were in date. These were available and accessible to staff. Records for the use of medicines in theatre were clearly written, allergies were recorded and venous thromboembolism (VTE) assessments were completed to ensure that patients were safe to continue with their procedures.

We saw that patients were asked about routine medicines that they took, and this was recorded in the clinical history. We were also shown how this was checked against suitability criteria for access to the service to ensure the right patients accessed the service. Staff reviewed patient’s medicines regularly and provided specific advice to patients and carers about their medicines. Staff explained to patients what medicines they were taking, in what order to take the medicines and what side effects could occur from the medicines. Where patients were supplied with medicines to take at home, a 24-hour contact number was available for advice.

The governance arrangements for the use of Patient Group Directions (PGDs) were robust and records of their use were clear and uploaded into patient records. PGDs are written instructions which allow specified healthcare professionals to supply or administer certain medicines in the absence of a written prescription.

The medicines fridge interior required defrosting. Although temperature monitoring records provided assurance that medicines were fit for use, we told staff the build-up of frost within the fridge could affect the temperature of internal areas within the fridge and may not ensure all medicines were kept at the same temperature. Staff arranged to defrost the fridge immediately.

Records showed that checks had been performed on emergency trolleys and kits to ensure that medicines within them were safe for use.