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Archived: Marie Stopes International Birmingham

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Reports


Inspection carried out on 21 June and 4 July 2019

During an inspection to make sure that the improvements required had been made

Marie Stopes International Birmingham is operated by Marie Stopes International.

The service provides termination of pregnancy as a single speciality service; We inspected this service using our focused inspection methodology. We carried out unannounced visits to Marie Stopes International Birmingham Centre on 21 June 2019 and 4 July 2019.

Marie Stopes International (MSI) Birmingham Centre, 4 Arthur Road, Edgbaston, Birmingham has five early medical units (EMUs):

  • Central Birmingham Early Medical Unit, Suite 204, 2nd Floor, Guildhall Building, Navigation Street, Birmingham,

  • Handsworth Early Medical Unit, Soho Road Health Centre 247-251 Soho Road, Birmingham

  • Sandwell Early Medical Unit, Glebe fields Health Centre, St Marks Road, Tipton.

  • Walsall Early Medical Unit Rushall Medical Centre, 107 Lichfield Road, Walsall.

  • Wolverhampton Early Medical Unit, Duncan Street Primary Care Centre, Blakenhall, Wolverhampton.(This was closed at the time of the inspection).

MSI Birmingham Centre (4 Arthur Road Birmingham), Central Birmingham, Handsworth, Sandwell, Walsall and Wolverhampton sites each hold a licence from the Department of Health (DH) to undertake termination of pregnancy services in accordance with The Abortion Act 1967. Services are provided predominantly to NHS-funded patients referred by local clinical commissioning groups, as well as to private patients.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? This inspection focused on the safe and well led domains as a follow up to the previous inspection in July and August 2017 which was published in March 2018. Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate. We did not rate this service as this was a focused inspection and the service had not previously been rated.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

This was a focused inspection of a service which had not previously been rated and therefore was not rated.

We found the following areas of good practice:

  • The service provided mandatory training in key skills to staff and most staff had completed it.

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.

  • Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.

  • The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.

  • Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care.

  • The service used systems and processes to safely prescribe, administer and record medicines. Improvement was needed to ensure safe storage of some medicines.

  • The service managed patient safety incidents well. Staff recognised and reported incidents and near misses.

  • Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff.

  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care.

  • Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact.

  • All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them.

However, we also found the following issues that the service provider needs to improve:

  • Whilst the premises were mainly observed to be visibly clean some areas within the treatment room were found to be dusty.

  • We were not assured appropriate stock rotation and monitoring of all medical devices was in place. Not all patient medical equipment was checked as required to meet legal requirements and provide assurance of patients’ safety.

  • Timely submission of notifications to external organisations was not always undertaken.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, to help the service improve. We also issued the provider with two requirement notices that affected Marie Stopes Birmingham. Details are at the end of the report.

Nigel Acheson

Deputy Chief Inspector of Hospitals

Inspection carried out on 20 and 21 July, 3 and 10 August

During a routine inspection

Marie Stopes International (MSI) Birmingham Centre is operated by Marie Stopes International, a not for profit organisation that was founded in 1976 to provide a safe, legal abortion service following the Abortion Act 1967.

MSI registered the Birmingham Centre with the Care Quality Commission (CQC) in July 2012.

MSI provides regulated activities at the Birmingham Centre and at seven other associated locations known as satellite clinics that provide early medical abortion. These are Central Birmingham Early Medical Unit (EMU), Sparkhill EMU, Erdington EMU, Walsall EMU, Wolverhampton EMU, Stourbridge EMU and Handsworth EMU.

MSI Birmingham Centre provides surgical termination of pregnancy procedures up to 23 weeks and six days along with medical termination of pregnancy and early medical termination of pregnancy up to nine weeks plus four days gestation. Surgical termination of pregnancy is available under conscious sedation, under general anaesthetic or no anaesthetic according to patient choice and needs. The service also provides family planning services, including advice on contraceptive options. The service provides oral contraception and long acting reversible contraception (LARC) as well as male sterilisation (vasectomy).

MSI Birmingham Centre provides services to adults and young people above the age of 15 years.

We had previously inspected MSI Birmingham Centre in June 2016 where we highlighted a number of concerns. We have had on-going contact with the provider since that time about the implementation of its quality improvement plan. We carried out this inspection to follow up on those concerns and to assess the improvements made by the provider.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key questions. We regulate termination of pregnancy services but we do not currently have a legal duty to rate them. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

Since our last inspection in June 2016, we have noted the following improvements:

  • A new electronic system for incident reporting
  • The introduction and monitoring of surgical safety checklists
  • The introduction of Termination Early Warning Scores (TEWS) used to detect deteriorating patients. However this was not yet embedded at the time of inspection.

We found the following areas of good practice:

  • There was an electronic incident reporting system in place to report incidents. Staff had received training in its use.
  • All MSI Birmingham Centre staff were trained to the appropriate safeguarding level. We saw good awareness and recognition of adult safeguarding, children’s safeguarding, child sexual exploitation (CSE), and female genital mutilation (FGM).
  • Mandatory training was provided in a range of topics, and management had the systems in place to monitor compliance.
  • Checklists were undertaken for all patients undergoing surgical procedures.
  • Patient records were accurate, complete, legible, up to date and stored securely. This was in line with the Data Protection Act, 1998.
  • Learning and development was provided at an appropriate level to enable staff to develop and maintain their skills and competencies in areas such as consent and scanning.
  • The clinic managed treatment in accordance with relevant, current, evidence based guidance such as Royal College of Obstetricians and Gynaecologists (RCOG) and National Institute of Health and Care Excellence (NICE).
  • Pain was assessed and treated in accordance with national guidelines.
  • We saw good multi-disciplinary teamwork in the clinic.
  • We observed staff treating patients in a non-judgmental, non-directive and supportive manner.
  • Patient satisfaction survey scores were consistently high.
  • Marie Stopes offered private telephone counselling for patients.This included issues such as miscarriage or ectopic pregnancy.
  • Staff had access to telephone translation services for patients whose first language was not English.
  • Staff discussed treatment options depending on the patient’s individual circumstances, needs and gestation.
  • The layout of the building did not support access to patients with physical disabilities. Therefore, staff were able to redirect disabled patients to an alternative clinic.
  • There were clear patient pathways for surgical and medical patients that eased the flow of patients through the clinic.
  • Between April 2016 and March 2017, all patients were offered an appointment in less than five working days from the decision to proceed.All patients had a procedure less than 10 working days from their first attendance. This was in line with RCOG guidance.
  • Staff were committed to the organisation’s vision of parenthood choice and women being in control of their own fertility. The organisation had developed a ‘Future Fit’ vision, although staff at the clinic did not refer to it.
  • Appropriate protocols were in place to comply with the Abortion Act (1967).The Department of Health licence requirements and Royal College of Gynaecologists recommendations for good practice.
  • There was an appropriate system in place to ensure HSA1 and HSA4forms were completed.
  • The provider organisation had identified the need for the service at the clinic to undergo a ‘supportive peer review’. It had begun to take urgent action just before our inspection visit to mitigate risks identified by this review.
  • The provider was taking action to reconfigure the management and governance arrangements to support the service.

However, we also found the following issues that the service provider needs to improve:

  • Staff incident report training was below the provider’s target. Staff told us they did not receive feedback either on an individual or group basis, therefore the systems in place to report incidents and learn from them, were not effective.
  • Compliance with training targets was not achieved; however, this was due to the high level of new starters in the clinic.
  • Some aspects of infection control needed improvement. For example, we found equipment to be dusty in both the day care room and treatment room.
  • We observed that clinical staff did not always decontaminate their hands immediately before or after every episode of direct contact or care in line with the World Health Organisation five moments of hand hygiene. For example, we saw staff removing their gloves but not washing their hands after patients contact.
  • We found that anaesthetists were not checking equipment on every day of use in line with Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidance.
  • We found the medicine cupboard did not lock therefore medicines were not stored securely.
  • Staff used the Termination Early Warning Scores (TEWS) to detect deteriorating patients. However this was not yet embedded at the time of inspection. This meant staff may not recognise patient deterioration in a timely manner.
  • We saw no identified restraint specific training or any other training that would indicate knowledge or understanding of restraint.
  • Due to the close proximity of recovery chairs and open plan layout, patients could overhear conversations with other patients. Staff were therefore unable to protect patients’ dignity and privacy.
  • There was a lack of clarity around what constituted a formal and informal complaint. We saw an example of how this had resulted in a complaint still being open after a three month period.
  • At the time of inspection the registered manager was in the process of applying to cancel their registration as they no longer had day-to-day responsibility for the MSI Birmingham Centre. Progress on the provider’s action plan to address required improvements identified at our 2016 inspection had been slow, not always effective and lacked oversight.
  • Staff did not feel engaged or supported in the change programme.

Heidi Smoult

Deputy Chief Inspector of Hospitals

Inspection carried out on 2 , 13, 15, 16 and 17 June 2016

During a routine inspection

Termination of pregnancy (ToP) refers to the treatment of termination of pregnancy by surgical or medical methods. Marie Stopes International Birmingham is part of the provider group Marie Stopes International (MSI). The service at MSI Birmingham was located within non-purpose built premises run by MSI. Seven satellite clinics connected to its registration operate around the city of Birmingham and in other towns nearby in a variety of leased premises including suites in community health centres. The services are provided under contract with local clinical commissioning groups for NHS patients. MSI Birmingham also accepts private patients.

The service was registered in July 2012 as a single specialty termination of pregnancy service providing a range of services for medical termination of pregnancy up to a gestation of 10+0 weeks and surgical termination of pregnancy up to 23+6(days). This included pregnancy testing, unplanned pregnancy counselling/consultation, early medical abortion, abortion aftercare, sexually transmitted infection testing, contraceptive advice, contraception supply and vasectomy services.

We carried out this announced comprehensive inspection on 2 June 2016, as part of the first wave of inspection of services providing a termination of pregnancy service. The inspection was conducted using the Care Quality Commission’s new methodology.

We have not provided ratings for this service. We have not rated this service because we do not currently have a legal duty to rate this type of service or the regulated activities it provides.

The inspection team included two inspectors, an assistant inspector and a consultant obstetrician and gynaecologist by phone.

To get to the heart of patients’ experiences of care, we always ask the following five questions of every service and provider:

  • Is it safe?
  • Is it effective?
  • Is it caring?
  • Is it responsive to people’s needs?
  • Is it well-led?

Our key findings were as follows:

Is the service safe?

Staff reported incidents but the systems that supported this were not reliable and investigation and learning was variable. There was sometimes delay in uploading reports to the electronic system, staff could not easily track the progress of incident investigations and some patterns of incident reported were not identified and investigated. Staff did not consistently follow some safety systems such as national guidelines to safer surgery, use of emergency equipment checklists and good hand hygiene practices. Not all staff were up-to- date with their mandatory training including safeguarding, life support skills and supporting anaesthesia. Many staff including local leaders had not undertaken safeguarding training to the level appropriate for degree of vulnerability presented by many patients. Staff followed policies and procedures for safeguarding children and vulnerable adults. Risks to patients were assessed and staff made referrals and emergency transfers to local acute hospitals when it was appropriate for patients. Sufficient numbers of experienced doctors and nurses staffed the service.

Is the service effective?

Systems in place to collect information about the effectiveness of the services did not provide the local leaders or staff with a clear picture of how their service was performing against regional and national clinical standards. Clinical audits recommended by the Royal College of Gynaecologists were not specifically addressed. The results of local audits did not always match with what we observed or the patterns of errors shown on the provider’s incident reporting records. There was no established pathway for effectively supporting women with learning disabilities to give informed consent to treatment. Health care assistants were taking consent to treatment without the appropriate level of safeguarding training and competency for the vulnerability and complex needs of many patients receiving the service.

Staff checked patient’s medical and health history before treatment and the clinic carried out only procedures for which it was registered and within national guidelines. Other patients were referred to more appropriate services to meet their needs. Patients were given information about contraception and sexually transmitted infection. Nurses and doctors were competent and worked with other healthcare providers locally for the benefit of patients.

Is the service caring?

Staff treated patients with respect, kindness, dignity and care. Patients spoke positively about staff attitudes towards them. Patients received a lot of information from staff about their treatment and a 24-hour help line was available to provide additional information and address concerns. Staff checked patients decisions at each stage of the process and went over the options with patients on more than one occasion. Counselling was made available to all patients over the phone or face-to-face. This was compulsory for patients under 16 years of age and we saw bookings on record with independent counsellors. There was no ‘easy read’ additional material available to enable patients with learning disabilities to access the information about treatment, treatment options and contraception.

Is the service responsive?

Services were planned to provide surgical and early medical terminations of pregnancy at a main clinic and in satellite clinics around the city and outlying towns within neighbourhood health centres. Patients accessed services and appointments through a national call centre, this system managed waiting times across clinics to respond flexibly to local demand, legal requirements, and targets set by commissioners of the services. Translation services were available to patients from the first point of making contact with the organisation and staff helped patients to access other services for help with domestic violence or drug abuse. Patients could receive counselling prior to receiving any procedures. There were a variety of means by which patients could comment on the service, raise concerns or make a complaint. Waiting times within the clinics was a challenge for the service and patient satisfaction with this had fluctuated during 2015/16. Access to some clinics was limited for people with some disabilities.

Is the service well led?

The provider had clear philosophical and political vision for the service and all staff at the clinics were committed to this, highly motivated and engaged in providing the best service they could to each patient. The clinics were led by a manager registered with the Care Quality Commission and staff felt well supported by the local leadership team. Patient’s views were routinely sought and there was engagement with the wider public and other professionals locally. The organisation aimed to improve by trying out new ways of providing the service and increasing its presence in new locations. However, the service had stretched its staff in order to set up a new service in the region at the expense of continuity of some existing clinics. Organisational structures in place to ensure legal compliance, manage risk and monitor quality had weaknesses that meant some risks, repeated mistakes and serious incidents were not properly dealt with and learned from.

We saw one area of outstanding practice:

  • Reception staff were highly skilled at putting patients at their ease and discretely confirming personal and private details when patients arrived including within small areas shared by other patients waiting for their consultations.

However, there were also areas of where the provider needs to make improvements.

Importantly, the provider must:

  • Put in place an effective incident reporting system that can provide assurance the provider can consistently learn from incidents and error, notify incidents to the appropriate authorities, and exercise its duty of candour.
  • Put in place effective cleaning arrangements in Birmingham Central clinic (Navigation St.).
  • Take steps to ensure clinical staff consistently follow good hand hygiene practices.
  • Ensure emergency equipment checklist systems are used effectively.
  • Ensure all staff are up-to-date with mandatory training.
  • Put in place protocols for obtaining consent, pathways, and support for all patients who lack capacity to consent, including those patients with a learning disability, in keeping with required standard operating procedures.
  • Ensure clinical audits recommended by the Royal College of Gynaecologists for termination of pregnancy are undertaken in order to continuously improve the services offered by the clinics and provide feedback effectively to staff about the services clinical performance.
  • Improve the reliability of local clinical and safety audits of MSI Birmingham and satellite clinics at Birmingham Central and at Erdington.
  • Put in place protocols to support getting informed consent for treatment from learning disabled adult patients.
  • Review the governance arrangements in place to provide effective assurance and auditing systems or processes.
  • More effectively assess, monitor and drive improvement in the quality and safety of the services provided.
  • More effectively assess, monitor and mitigate any risks relating to the health, safety and welfare of people using services and others.
  • Continually evaluate and seek to improve governance and auditing practice.

In addition the provider should:

  • Consider major incident planning in particular for the Birmingham Central (Navigation St.) clinic.
  • Explore methods of giving patients with learning disabilities access to information about the service and their treatment so they can have a better understanding and be involved.

Due to the number of concerns arising from the inspection of this and other MSI locations, we inspected the governance systems at the MSI corporate (provider) level in late July and August 2016. We identified serious concerns and MSI undertook the immediate voluntary suspension of the following services as of 19 August 2016 across its locations, where applicable:

  • Suspension of the termination of pregnancy for children and young people aged under 18 and those aged 18 and over who are vulnerable, to include those with a learning disability
  • Suspension of all terminations using general anaesthesia or conscious sedation
  • Suspension of all surgical terminations at the Norwich Centre

MSI responded to the most serious patient safety concerns we raised and was able to lift the restrictions on the provision of its termination of pregnancy services at this location on 7 October 2016.

CQC has also undertaken enforcement action for breaches of the following regulations, which are relevant to this location.

Regulation 11 Consent

Regulation 12 Care and treatment must be provided in a safe way for service users

Regulation 13 Service users must be protected from abuse and improper treatment in accordance with this regulation

Regulation 15 Premises and equipment must be kept clean to the standards of hygiene appropriate to their purpose.

Regulation 17 Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part (Good governance)

Regulation 20 of the Care Quality Commission (Registration) Regulations 2009

CQC is actively monitoring compliance with the above enforcement action taken in order to ensure that services are operated in a manner, which protects patients from abuse and avoidable harm.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 10 December 2013

During a routine inspection

We visited the main Birmingham clinic but we did not visit the satellite clinic, this had been providing services for only a few weeks at the time of our inspection. During our visit we asked the nursing staff to notify people using the service that we were visiting and would be happy to speak to them. Three people agreed to speak with us about their views of the service they had received. They told us they were satisfied with the service they had received. One person told us “I wasn’t very happy before I came here today, I was very nervous and distressed but now I feel relieved”.

People who used the service were given appropriate information to help them understand their treatment. Before people received care or treatment they were asked for their consent.

The provider had an effective system in place to continuously monitor the quality of the service. We found that the systems for record keeping and managing medicines had improved since our last visit.

Inspection carried out on 19 November 2012

During a routine inspection

During our visit we spoke with six members of staff in addition to the registered manager. During our visit we asked the nursing staff to notify people using the service that we were visiting and would be happy to speak to them. Two people agreed to speak with us about their views of the service they had received. People using the service told us that they were happy with the care they received at the clinic. They told us that their care and support needs were being met.

People told us that staff explained their care, treatment and support choices to them. This meant that they had the opportunity to be involved in making decisions about their care. A person using the service told us ‘’The doctor talked me through all the treatment options.’’

We found that the systems for record keeping and managing medicines were not sufficiently robust and improvements were needed.

We found that the systems for monitoring the service to ensure that people received a quality service were satisfactory.

Marie Stopes International became the registered provider for this clinic in June 2012. During our inspection, we asked the commissioning team at the local primary care trust about the quality of the service the clinic provided. They did not have any information to share with us about the quality aspects of the service.