BPAS - Stratford upon Avon

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 Safeway. The environment was safe and well maintained. Good levels infection prevention and control maintained throughout the service. We found the resuscitation trolleys to be fully stocked with the relevant expected equipment available.

At our last assessment, we rated this key question requires improvement. At this assessment, the rating has improved to good. This meant patients’ needs were met through good organisation and delivery.

We have not awarded this service a score for Safe.

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

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.

The service had a proactive and positive culture of safety, based on openness, transparency and honesty. Staff listened to concerns about safety and fully investigated and reported safety events. Lessons were learnt to continually identify and embed good practise. For example, instances of retained products of conception were always be reported as an incident and any learning identified was cascaded to staff.

Incidents were reported through an electronic reporting system, which all staff had access to. Staff received feedback from incident reviews and investigations. Learning was shared through team meetings, organisational learning forums and newsletters.

Leaders and staff were fully aware of their responsibilities for reporting incidents, accidents and concerns. These were reported and managed in line with the service's Patient Safety Incident Response Framework policy

Staff told us they felt able to raise incidents and concerns with both colleagues and leaders without fear. Staff survey findings and organisational policies demonstrated a positive culture focused on learning and improvement.

Data showed that between 1 July 2025 and 30 June 2026, 60 incidents were reported within the Stratford-upon-Avon service. The evidence reviewed did not identify any declared Serious Incidents or Patient Safety Incident Investigations (PSIIs) for the service during this period.

There were policies and procedures which provided guidance on the requirements of Duty of Candour. Senior staff were knowledgeable about these requirements and demonstrated an understanding of their responsibilities regarding openness, transparency and learning following incidents.

The service worked with people 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 people moved between different services.

Staff had access to clear and documented systems to ensure patient risks were identified and managed. These systems support the safe delivery of care to patients. The service worked with patients and those close to them to establish and maintain safe, effective treatment and care to eliminate risks and ensure continuity of care.

Discharge letters present in the patient's records were reviewed, which included that contraception had been discussed with patients choosing to seek further support or treatment from the GP. With the patient's consent, electronic records and images could be shared with other healthcare providers in line with data protection.

The service had a policy for when a patient would need to be transferred to a hospital in case of an emergency. The policy named the hospital and was detailed and up to date. Other policies within the service included the action staff should take for female genital mutilation and awareness of child sexual exploitation.

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 women choosing to continue with their pregnancy were advised to see their General Practitioner (GP) and were informed about self-referral to maternity services. Community midwives were notified where appropriate to ensure continuity of maternity care.

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

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 support patients who were victims of crime.

During consultations patients were seen on their own for part of the process, this meant patients had the opportunity to disclose any safeguarding issues that 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 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 the 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 to their role on how to recognise and report abuse. At the time of inspection, 100% of staff had attended Level 3 safeguarding children and adults training and 100% of staff had attended Level 2 safeguarding children and adults training against the service target of 85%.

Staff also achieved 100% compliance in associated safeguarding training, including Prevent, Mental Capacity Act 2005, Domestic Abuse and Domestic Abuse, Stalking and Honour-Based Violence (DASH) training. Safeguarding supervision compliance was 87.5% against the service target of 85%. Refresher training and safeguarding supervision were undertaken in line with organisational requirements.

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 maintained emergency equipment to support the safe management of clinical emergencies. Staff undertook monthly audits of all equipment held within the resuscitation trolley drawers. During inspection, the resuscitation trolley checklist had been fully completed and all required equipment was present. We found no missing or out-of-date items and observed that the trolley contained the necessary emergency equipment, including ligature cutters, in line with Resuscitation Council requirements.

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 procedure 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 that legislation was met. Staff also completed HSA4 forms to notify the government about each early medical termination which took place. Completion of both forms were monitored by the service weekly.

Staff used recognised tools to improve the detection and response to clinical deterioration in the modified Termination Early Warning Score (TEWS) (a system used tool 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 midwives’ professional judgement. Records showed staff had identified deteriorating patients and treated them accordingly.

There were processes in place to respond to medical emergencies. There were formal processes to transfer patients to the local NHS hospital. All out of hospital tranfers were jointly monitored and reviewed by the service and hospital.

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

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’s sepsis screening and action tool was also included in the 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 10 risk assessments and saw that they were all completed correctly in line with the service policy and suggested national guidance.

Patients were given extended appointment times dependent on their age and safeguarding risk, which allowed staff to adapt patients’ consultations 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 were 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 service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

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

All areas of the clinic were observed to be visibly clean and tidy, including the reception and waiting area.

The service was on the ground floor, and easily accessible with a reception area which overlooked a spacious, clean and tidy waiting room. Patients were seen in private individual consultation and treatment rooms, which helped promote privacy, dignity and confidentiality. There was also a separate area available to be used as an additional waiting space when an identified need arose, supporting patient comfort and privacy.

The environment was visibly well-maintained, with sufficient space for patients and staff to move around safely. The layout supported the delivery of care in a calm and respectful setting and enabled patients to access services in a way that protected their privacy throughout their visit.

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 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 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 doctor, 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 mandatory training for staff, including Manual Handling, Health and Safety, Duty of Candour, Safeguarding, Prevent and Infection Prevention and Control. At the time of inspection, clinical staff mandatory training compliance ranged from 94% to 100%, with clinical management achieving 100% compliance against the service target. Staff completed refresher training in line with organisational requirements

Staff at all levels received regular appraisals, which provided opportunities for professional development, career progression and wellbeing support. At the time of inspection, 100% of staff had completed their annual appraisal against the service target

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

We observed that 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 patients’ needs.

We spoke with 5 patients who told us there always appeared to be enough staff to provide good care. One woman told us she was very happy with the service. She spoke positively about the “Telemed” telephone service, the timely booking process and the support provided. She said BPAS staff were “really good” and never too busy to answer questions or discuss any concerns.

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.

The service-controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept the equipment visibly clean.

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 Infection prevention control (IPC) procedures were undertaken correctly during all the clinical procedures, and all sharps were correctly disposed of in the sharps bin. We observed equipment had ‘Green I am clean’ stickers on once they had been cleaned and were ready for use.

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.

Staff undertook Infection Prevention and Control audits across the service for infection prevention and control, hand hygiene and uniforms. Data reviewed between January 2026, and May 2026 showed 100% compliance for hand hygiene and uniform audits. Environmental cleanliness audits achieved 96.5% compliance in January 2026 and 100% compliance in April 2026 following improvement actions. Sharps, waste, linen and Personal Protective Equipment audits also demonstrated 100% compliance during the reporting period.

Infection control was part of mandatory training for all clinical staff.

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

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, suitable patients 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 were found to be in date and correctly stored.

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