BPAS - Stratford upon Avon

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

There was a shared vision, strategy and culture. Staff were committed to their work and responsive to the needs of patients. There was a focus on patient safety and care. There was confidence in leadership and staff felt supported by managers. There were processes to support staff who required reasonable adjustments. Staff liked working in the service and worked well together as a team. Management had a visible presence at the service.

Leaders supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last inspection, we rated this key question good. At this inspection 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 Well-led.

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

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The BPAS organisation had an overall corporate strategy and business plan which were accessible to all staff. The aims were to remove barriers to reproductive choice by providing high-quality, patient centred care through service delivery, advocacy, campaigning, and research. Its strategy involved expanding services to include areas such as supporting the workforce, investing in digital tools, and generating research to inform policy and practice.

The vision of the service was to provide inclusive, reproductive health care services that are responsive to the needs of everyone who wishes to use them and to promote the development of services that are accessible, effective, safe and confidential.

BPAS emphasised patient involvement in shaping its services and sought to build collaborations to advance reproductive healthcare.

Staff told us they understood and knew the principles and values, and they believed the service worked well to achieve them.

Staff told us they felt there was a positive culture within the service, they told us they felt managers and senior managers were approachable and supportive.

We observed positive relationships between medical staff and nursing staff, with the patient at the centre of the service.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in and around the clinic. They supported staff to develop their skills and take on more senior roles.

Staff told us they were encouraged to speak up and discuss their concerns openly. When staff had raised concerns, they felt the management team were capable of taking appropriate action.

Leaders engaged with staff and used staff survey results to explore issues and discuss solutions and improvements.

We observed positive and professional interactions between all members of staff regardless of seniority.

There was a clear sense of teamwork, and everyone spoke highly of their colleagues. When talking with staff it was clear that their priority was focussing on the needs of the patients they cared for.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff felt supported and were able to develop to improve their practice. There was evidence of an open and supportive culture with mutual respect throughout, regardless of the role of the employee.

Managers and staff understood the importance of staff being able to raise concerns without fear of retribution. Freedom to speak up was part of mandatory training.

The wider provider had appointed 6 freedom to speak up guardians (FTSUG), across the BPAS organisation. There was a corporate freedom to speak up policy and procedure, which staff were knowledgeable about.

Staff could raise concerns with any of the FTSUG people listed by phone, by e-mail or face to face. There was also a link on the internal intranet for staff who wished to raise a concern but wanted to remain anonymous.

Staff told us they were aware of the freedom to speak up guardians, and they knew how to contact them if they needed to raise any concerns and wanted to raise them confidentially.

However, they told us that they would raise any concerns with the manager, as they felt confident that any concerns raised would be addressed by them. Staff told us they felt confident to escalate matters if they felt their concerns were not being responded to.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff and leaders told us, and we saw during our assessment there was a diverse workforce with a positive sense of inclusion. Managers told us they made workplace adjustments where necessary. For example, if staff wanted to change their working arrangements either temporarily or on a permanent basis.

Staff we spoke with told us they felt valued and respected, and spoke highly about their colleagues and managers.

The service had an open culture where patients, their families and staff could raise concerns without fear.

There was a policy on equality of opportunity at work, this meant recruitment decisions were based on the candidate’s ability to undertake the job and eliminated discrimination on any grounds. Recruitment packs included an equal opportunity monitoring form.

Training was available for all staff in Equality and Diversity and this was a mandatory requirement. At the time of inspection, 100% of staff had completed Equality and Diversity training against the service target. Compliance was monitored through the service's mandatory training programme

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leaders operated effective governance processes throughout the service. Staff at all levels understood their roles, accountabilities and had opportunities to meet, discuss and learn from the performance of the service.

Committees were in place to oversee key areas of the organisation, including information governance, quality and risk, infection prevention and control, and research and ethics. Information was shared between these committees and communicated to staff through regular management and staff meetings. The organisation also had a Clinical Advisory Group made up of internal and external clinical experts, who provided advice and oversight on clinical policies and practice.

Leaders provided oversight and governance arrangements that enabled risks, performance and outcomes to be identified, reviewed and acted upon. Systems supported the secure and timely sharing of information with relevant professionals to maintain continuity, safety and quality of care.

Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.

During our inspection we observed that all professional clinical staff were registered with the appropriate professional body, and the service had systems in place to ensure that revalidation took place as required.

The service had a risk register, which we reviewed as part of our assessment. Risks related to safeguarding, transfer arrangements, scanning capacity, medicines management, workforce training, Information Technology resilience and service continuity. Risks had been identified, mitigating actions, assigned leads and review arrangements and were monitored through the service's governance processes.

Senior staff and executives were present and visible daily.

Service leaders had a clear vision for the continued development of the service and reviewed capacity and access to care regularly.

Patient choice was prioritised and appointments were available seven days a week. Arrangements were in place to support patients with travel, accommodation and transport costs where required. Staff told us they felt supported by local leaders and described a positive team culture.

Learning from incidents was shared through patient safety event learning responses, organisational shared learning events, regular safety bulletins, bite-sized learning (‘safety pins’) and professional peer meetings, which supported continuous improvement and the dissemination of good practice across the service.

The service understood their duty to collaborate and work in partnership with other agencies, so that services worked seamlessly for patients.

The service worked with local health care partners to ensure there was a good understanding of local needs and to improve the care they provided. The service had transfer protocols in place with the local NHS hospital.

The service operated as part of a network of British Pregnancy Advisory Service (BPAS) clinics and worked collaboratively with external partners, including General Practitioners (GPs), acute hospitals, community midwives, social care services and safeguarding teams, to support safe and coordinated care. There were regular meetings between BPAS clinics across the country, which provided opportunities to share information, learning and best practice. These forums were used to review learning from serious incidents, complaints and safeguarding concerns, helping to promote consistency, improve quality and strengthen outcomes for people using the service.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The service was committed to continuous learning, innovation and improvement in order to be more efficient and improve outcomes for patients.

Staff told us that information was sent by email but also followed up face to face in team meetings.

Staff described a culture of learning and of opportunities to develop their knowledge and skills for example the service had adopted and implemented the Patient Safety Incident Response Framework (PSIRF) to ensure the response to patient safety incidents was focused on compassionate involvement and learning.

At the time of our inspection this approach was continued to be embedded across BPAS and included an active learning culture for staff.

The service were active members of the British Society of Abortion Care Providers, participated in research and had a research and ethics committee.

The service recognised the value of patient feedback and actively encouraged this through a number of routes including the Friends and Family Test (FFT) and formal and informal complaints. The service worked with a patient safety partner who provided insight and support for a range of patient safety responses.