BPAS - Sandwell

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

We looked for evidence that patients and communities had the best possible outcomes because their needs were assessed. We checked that patient’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring patients were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

At our last inspection we rated this key question good. At this inspection the rating remained good. This meant patient’s outcomes were consistently good, and patient’s feedback confirmed this.

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 patient’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Patients were involved in the assessment of their needs, and support was provided where appropriate. Patients self-referred to the service and there was a comprehensive approach to assessing the needs of the patient. Staff were passionate about providing the most up to date evidence-based practice in line with national guidance to make sure patients had the best outcomes for them.

Patients filled in a medical questionnaire and answered initial triage questions when they booked in through the telephone booking service. This ensured all patient care was individualised. Triage questions led to more questions depending on the answers the patients gave. We saw examples of an in-depth assessment due to a patient answering that they had ‘asthma’ to ensure all health needs were discussed. Patients’ conditions were discussed pre-operatively and advice was given to women who proceeded to surgery regarding management of these conditions where required.

Patient’s pain was assessed throughout their surgical procedure and post operatively. Information given prior to their treatment, whether it was surgical or abortion pill treatment at home, gave information about pain. This included quotes from patients about what they might expect and how they described their pain. There was also a QR code patients could scan to hear more experiences from patients to help prepare them.

Pain was measured for patients who had early medical abortion completed at home. They filled in a satisfaction survey which measured the levels of pain they experienced. Results between January and December 2025 were mixed. There was no trend and similar numbers of patients had more pain than they expected as patients who had less pain than expected. Over 70% of patients in 2025 said the information on the website and in the leaflets prepared them for the pain they experienced.

Patient’s communication needs were assessed and met to maximise the effectiveness of their care and treatment. The service website had a function where all information could be translated into numerous languages. Staff used telephone interpreters, and this was identified at the initial booking process. They had recently upgraded their telephone system in the clinic to improve the access to interpreters.

Incidents reported at Sandwell between August 2025 and January 2026 included the unavailability of interpreters at the time of surgical admissions. These were escalated to the language service provider, with feedback shared and reviewed through monthly meetings involving the provider and the organisation’s language service lead. BPAS had updated their patient information and provided videos and information available via QR code for accessibility, as well as telephone support for patients who are unsure of how to take their medication.

The service had a ‘Pathway Adjustments’ function on the electronic patient record. This enabled staff to record if a patient needed additional support during their pathway and the pathway could then be adjusted accordingly. Staff made reasonable adjustments to ensure patients were well supported throughout their journey. Staff gave examples including if a patient disclosed they had a learning difficulty, they would make the following adjustments: dedicated support person; extended appointment; language adjustment.

Patient’s social situations were assessed, and support was offered post discharge where needed. We saw examples where patients under the age of 18 had attended clinic and did not have an adult over the age of 18 with them and did not want to tell their parents. The service had multidisciplinary meetings about these cases, involving social services if they were known to them, and ensured there was a support plan in place. These patients had a follow up call from the nursing team post procedure to ensure they were okay.

Staff had received training to support them to engage with patients with additional needs. Data showed 92% of staff had completed training on learning disability and autism.

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

Patients received care, treatment and support that was evidence-based and in line with good practice standards. There was a national team within BPAS who reviewed national legislation and updated policies and procedures in line with these. This included National Institute for Health and Care Excellence (NICE) guidelines and Royal college of Gynaecology (RCOG) guidelines. Updated policies were reviewed in the monthly quality review group. Updates were then disseminated to staff through the internal communications channels. The Lead Nurse printed new policies and created a signature sheet for staff to sign once they read them.

The provider’s policies were uploaded onto a database for staff to read. We reviewed several policies and saw they were all up to date and referenced national legislation and guidance. Staff gave an example that the resuscitation guidelines had been updated in 2025 and they had changed the policy in line with this.

Staff followed established service-wide governance processes to ensure compliance and maintain standards. Staff consistently reviewed performance and compliance using a comprehensive audit schedule documented on the local clinical audit compliance board (LCACB). Audits were monitored by the Lead Nurse and the Quality Matron monthly who ensured action plans were created and completed to improve practice. For example, the Quality Matron noticed the consent audit results were low. The results showed staff were not evidencing a copy of the consent was being given to patients. Following a detailed review of the audit results, the service identified that the issue related to the design of the audit tool rather than staff practice. Compliance was confirmed to be good. Staff were subsequently provided with refresher guidance to ensure the audit was completed accurately and consistently.

There was an LCACB action tracker and we saw actions were consistently completed throughout 2025. There were 2 outstanding actions on the tracker at the time of the inspection which were due to be completed during a meeting the following day.

Audit results were presented at a monthly integrated performance review by the Quality Matron and Operations Manager. This ensured the senior leadership team were sighted with all audit results and actions within the clinic.

Patient’s nutrition and hydration needs are met in line with current guidance. Patients who attended for surgery were offered a hot drink and a biscuit following their procedure. Patients were not required to starve prior to their procedure as they were not performed under general anaesthetic. Patients were given anti-sickness medication post procedure if required.

The service worked effectively across teams and with other services to support patients. Staff ensured patients only needed to share their information once by appropriately sharing assessments when patients moved between services.Staff had access to the information they needed to appropriately assess, plan and deliver patient’s care, treatment and support. All patients who needed surgery had a pre-operative assessment and an ultrasound scan to ensure they were suitable in line with their criteria. The service only operated on women until they were 13 weeks and 6 days pregnant. If they were found to be over 14 weeks pregnant, they were referred to another clinic in the region where they could undertake later terminations.

There were systems in place to support patients who had serious complications in theatre or the recovery area. There was a deteriorating patient policy and staff had monthly practice emergency scenarios to ensure they were competent with dealing with different emergency scenarios. Women were transferred to the local acute trust if necessary, and staff were able to contact gynaecology teams directly with referral information.

Patient surgical notes and handovers between theatre and recovery followed the situation, background, assessment and recommendation (SBAR) format. Notes were easy to read and contained pertinent information for transferring patients between teams.

Staff shared information with other termination of pregnancy providers in the area and aligned their policies. They shared safeguarding information about patients when other services needed to be on alert regarding their care. Staff told us they worked well together.

Information was shared between teams and services to ensure continuity of care, for example when patients were referred between services. The service had direct access into an early pregnancy assessment unit (EPAU). They had improved this relationship recently by changing their policy to only scanning women who were over 5 weeks pregnant as previously had scanned under this and referred women to the EPAU and this had caused issues.

On surgery days there was a surgical huddle at the start of each list where the theatre team discussed each patient individually including any additional needs such as allergies.

When patients received care from a range of different staff, teams or services, it was co-ordinated effectively. All relevant staff, teams and services engaged in assessing, planning and delivering patient’s care and treatment and staff worked collaboratively to understand and meet patient’s needs. Staff involved the multidisciplinary team (MDT) for complex cases to ensure the right care was delivered to the patient. This included involving social services if the patient was known to them. They created individualised care plans for patients who needed it following MDT meetings.

The BPAS clinics worked closely together to maximise efficiency and reduce waiting times to benefit patients where possible. There were 3 continuity nurses for the region who were shared across different clinics working where they were needed the most.

Patients were asked for permission to contact their GP. With consent, GPs were contacted for information such as medication, medical conditions, or safeguarding concerns and they received a copy of the discharge letter. GPs were informed if a patient decided to continue the pregnancy or presented with a gestation of above 24 weeks for antenatal care.

BPAS Sandwell had well-established relationships in the wider health community. They had transfer agreements with a local NHS trust. Staff had established relationships with acute providers and departments such as Gynaecology and the emergency pregnancy assessment unit to ensure smooth transfers when needed.

The service worked with sexual health services within the area to refer patients. They also signposted to and shared service information with local services including drug and alcohol support services, women’s services, homeless and housing support and services that support ethnic minority groups. These stakeholders are often members of the local Sexual Health Boards and Partnerships.

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

Patients were encouraged and supported to make healthier choices to help promote and maintain their health and wellbeing. The service had relevant information promoting healthy lifestyles and support. Women received contraception advice and had the option of having an intrauterine contraceptive inserted at the time of surgical termination. Early medical abortion packs had contraception advice booklets and contraception in each pack. Women could receive oral contraceptive pill prescriptions at the service.

The service supported patients to make healthier lifestyle changes, such as stopping smoking, improving diet, or increasing physical activity and were able to signpost into local services.

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

Patient outcomes met agreed expectations as set out in legislation, standards and evidence-based clinical guidance.

There was participation in relevant local and national clinical audits and other monitoring activities such as reviews of the services, benchmarking and peer reviews. The peer review was a mock CQC audit which aimed to improve care for their patients. Staff used peer review to identify areas for improvement and was completed by managers who worked outside of the region of the clinic. The service had a peer review in summer 2025 with minimal actions to take for improvement.

The service had key performance indicators (KPI) which were looked at by senior leaders monthly and included escalation of key risks and concerns. KPI’s included waiting times for treatments and consultation. The service generated a weekly activity report. In most weeks, the clinic exceeded the number of appointments they had for early medical abortion, surgical procedures and ultrasound scans. For example, they were budgeted to carry out 30 ultrasound scans per week and on average they undertook 54 scans per week. The Treatment Unit Manager looked at the lists daily and was dynamic in ensuring more appointments were made available when required. This meant they did not have long waiting times. For example, on 27 January 2026 there was a 2 day wait to be seen.

There were effective approaches to monitor patient’s care and treatment and their outcomes. Outcomes were monitored by senior managers. Complications included retained products of conception, ectopic pregnancy, complex safeguarding cases and excessive pain. Patients had access to a 24-hour aftercare service, and the outcomes were monitored by this team. Where themes were identified, these were communicated to the relevant teams.

The service looked at patients who ‘did not attend’ post treatment checks; the rate was 32% within the division. Patients who were flagged as high risk, such as safeguarding needs or under the age of 18, would be followed up by the nursing team. There was a flowchart for staff to follow to ensure patients were managed appropriately.

The service offers 2 bookable service slots for patients who have retained products of conception following a failed early medical abortion (EMA). This was a risk of an EMA and was clearly documented within the information leaflets patients received including the likelihood, which was 5 in 100 patients.

The service completed and returned patient analysis data for each termination of pregnancy to the Department of Health (HSA4 report).

The service leaders had scheduled to meet with the integrated care board quarterly and presented data to them regarding patient outcomes, however 2 of these meetings had been cancelled due to sickness. Therefore only 1 meeting occurred in 2025 with the ICB. We reviewed meeting minutes from March 2025 meeting and saw quality assurances was discussed.

The service worked with local public health teams and provided data that supported public health teams to identify areas of high termination of pregnancy or repeat terminations as this may indicate a need for additional contraception provision or/and sexual health education. The service had also provided data on patients that had accessed their service for a termination who have had a live birth in the previous 12 months, this may indicate a need to provide contraception services on maternity wards.

Patients understood their rights around consent to the care and treatment the service offered. Patients were given information about their proposed treatment both verbally and in written form, to enable them to make an informed decision about their procedure. All patients self-referred into the service.

Patients views and wishes were considered when their care was planned. Staff discussed treatment options available to ensure they consented to treatment based on the information available. Patients received information about care and treatment in a way they could understand and had appropriate support and time to make decisions.

Staff understood the importance of ensuring that patients fully understood what they are consenting to and the importance of obtaining consent before they delivered care or treatment. Staff recorded consent in patient’s records at their initial appointment, and this was then printed off on the day of surgery and signed. Care records showed consent forms were signed for all records reviewed.

We observed a consultation where consent took place. We found the staff were engaging with the patient, provided appropriate information and completed the consent alongside the patient while checking their understanding.

The service ensured patients were consented in line with their policy. They audited the completion of consent forms monthly and reported this to the senior leadership team through governance.

The clinic had a policy outlining the principles of consenting patients, including those under the age of 18 and of capacity to consent. The service audited their consent forms and found consent was gained in line with required BPAS policies and procedures. The most recent consent audit was 86%. The quality manager investigated it and found all consent had been completed and copies of the consent forms had been given but it had been wrongly documented within the system. They were re-educating staff about the audit completion.

Staff ensured patients were seen alone to minimise the risk of coercion by a third party.

Patients were given information about the disposal of the pregnancy remains; this was discussed at their initial appointment with the nurse.

Staff understood Gillick Competence and Fraser Guidelines and supported children who wished to make decisions about their treatment and how this would be safely managed. Girls and young women under the age of 18 years had to be accompanied by a person over 18 years when they left the service and staff checked this. Where this could not be achieved, they had a multiagency meeting and plans to ensure the girls and young women were cared for. Where necessary advocates were used to support girls at risk. All patients under the age of 18 had an encrypted video call at their initial call and they had to show the staff around the room to show they were alone and not being coerced into the decision. Staff had access to advice and support if they had any concerns regarding consent. The youngest they would see was age 12.

Patients’ capacity and ability to consent was considered and they were involved in planning, managing, and reviewing their care and treatment. Where further support was needed regarding consent a multidisciplinary meeting would be undertaken and processes followed in line with their policy.

Staff were aware of the legal requirements of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards. All patients answered mental capacity screening questions at their initial telephone booking in appointment. However, this had recently been highlighted by the head of safeguarding that it was not compliant as it was not specific to paediatrics and adults, so it was under review at the time of inspection. Data showed staff were 100% compliant with MCA training and consent mandatory training. December 2025 Quality and Risk Group meetings showed staff had a discussion around renewing MCA and Gillick competence training and review of the policy following an incident at another clinic where an under-16 had been assessed under the MCA rather than Gillick competence.