BPAS - Stratford upon Avon

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Patients received good outcomes. During our assessment, we observed that people’s care, support and treatment reflected their needs.

The service protected individuals from discrimination. This ensured patients were at the centre of their care.

Staff worked to ensure that current outcomes and exploring best practice was part of their everyday work.

Patients were active partners in the assessments of their needs. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, supported them to make decisions about their treatment, and had access to good information. The service had policies and care pathways in place that were in line with national guidance.

The service completed a range of audits and worked well together as a multi-disciplinary team.

At our last assessment, we rated this key question good. At this assessment the rating has remained the same. This meant people’s needs were met through good organisation and delivery.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

All patients we spoke with as part of our inspection told us they were informed about their care and termination procedure; they felt staff assessed their needs and treated them holistically and as individuals.

Staff worked together as a multidisciplinary team with the GPs and other health care partners to benefit patients and provide the best outcomes for them.

Staff used appropriate assessments and completed and updated risk assessments for each patient. Staff identified and quickly acted upon patients at risk of deterioration. Patient needs were escalated appropriately.

Staff kept detailed records of patients’ treatment and aftercare. We looked at 11 patient records and found they were clear, up to date and easily available to all staff providing care. All records were maintained electronically.

Patients were able to self-refer privately or access services via an NHS referral. Initially, all patients completed a health questionnaire, which was reviewed in advance of an initial assessment and evaluation.

People we spoke with told us they felt staff understood their physical and emotional needs, especially if they were anxious about their proposed treatment.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

The service provided care and treatment based on national guidance and evidence-based practice that were up to date and accessible to staff on the electronic intranet. Staff provided care and treatment based on national guidance and evidence-based practice.

Policies and procedures, assessment tools and pathways followed recognised and approved national guidelines. Care and treatment were delivered in line with legislation, standards and evidence based guidance. For example, the service could access support if they were concerned about a patients mental health. The medical questionnaire completed by patient’s asked for information about mental health problems including post-natal depression which is recognised best practice. Staff referred to the psychological and emotional needs of patients and this was documented in their records.

Policies relating to termination of pregnancy were developed in line with the Department of Health Guidance: Abortion: procedures for approval of independent providers. Staff were aware of how to access relevant policies and procedures. Staff were given regular updates if and when guidance was reviewed or practice changed.

Staff shared key information to keep patients safe when handing over their care to other staff during the daily morning huddle meetings. The service monitored the effectiveness of care and treatment and used the findings to improve them.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff held regular and effective team meetings to discuss patients and improve their care.

We observed good team working throughout the service, attended by the clinical and non clinical staff who worked together as a team to benefit patients. Staff told us they also liaised regularly with local maternity services, safeguarding services and patients’ GPs. There was evidence that the team meetings were inclusive and well organised.

Information was shared with GP’s and other community services as appropriate to improve the continuity of care for the patient. The electronic patient record enabled timely access to information and diagnostic test results during consultation which contributed to patients making informed decisions about their care and treatment.

All staff had appropriate access to patients’ records to ensure treatment was delivered in line with best practice. Staff shared relevant parts of patient records with other organisations, with consent from the patient, such as the patients’ GP.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Staff gave patients practical support and advice to lead healthier lives. There were a number of patient information leaflets on pregnancy related matters, sexually transmitted infections and contraception. Information was also displayed on notice boards. During a consultation we observed staff discussed contraception in detail with a patient who was preparing to undergo a termination.

The information leaflets were available in languages spoken by patients and the local community. The central booking system allocated longer appointments for patients who required an interpreter.

Contraception was discussed at pre-assessment, including long acting reversible contraception, and condoms were offered.

Information on contraception and sexually transmitted diseases was also included in the ‘My BPAS’ booklet given to every patient.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service participated in national benchmarking clinical audits with other BPAS clinics, this allowed the service to benchmark their clinical outcomes and use the findings to improve standards or highlight their achievements with staff and patients.

BPAS completed monthly audits against a range of organisational standards which were reported through a national dashboard. The dashboard provided oversight of clinic performance and compliance across BPAS services and included audit findings relating to medicines management, consent documentation, consultation record keeping, Patient Group Direction compliance and controlled drugs governance. Individual standards were rated using a Red-Amber-Green (RAG) methodology, with green indicating compliance and red indicating non-compliance. We reviewed the most recent available dashboards for February, March and May 2026, which demonstrated compliance with the standards assessed and provided organisational assurance regarding quality, safety and governance. The dashboards formed part of BPAS's governance framework and were used to monitor performance, benchmark services and identify opportunities for improvement across clinics.

Managers and staff carried out a comprehensive programme of repeated audits to check improvement over time which included medicines management, consent form completion and contemporaneous consultation notes. Managers shared and made sure staff understood information identified from the audits. This was undertaken at regular team meetings and by e-mails.

Patients were encouraged to provide feedback following their treatment by completing the Friends and Family Test and patient satisfaction surveys.

Data showed 100% positive feedback for telephone consultations, face-to-face consultations and Early Medical Abortion services between January and March 2026. Ultrasound services received 95% positive feedback during the same period. Patient satisfaction reports also demonstrated consistently positive feedback from patients during October to December 2025.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff gained consent from people in line with legislation and guidance, which was documented within patient records.

The service talked about consent at two stages of the patients care and treatment to ensure patients were fully informed of the potential risks of their procedure.

The consent form was available in 16 different languages. The service used a recognised language interpretation service by telephone or face to face if necessary. A hearing loop system was also available. A hearing loop (sometimes called an audio induction loop) is a special type of sound system for use by people with hearing aids.

Patients could request a chaperone, notices containing this information were clearly displayed in waiting areas.

Patients received appropriate information prior to their procedure. Staff made sure they understood the information.

Staff were aware of Gillick competency and Fraser guidelines. Gillick competence is concerned with determining a child’s capacity to consent. Fraser guidelines are used specifically to decide if a child can consent to contraceptive or sexual health advice and treatment.

We looked at 6 sets of patient care records and saw that consent was appropriately recorded in all of them.

Staff we spoke with understood the requirements of the Mental Capacity Act 2005 and the two-stage process.