BPAS - Sandwell

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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that patients were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We checked the environment was safe, and patient risks were managed.

At our last inspection we rated this key question good. At this inspection the rating has remained good. This meant patients were safe and protected from avoidable harm.

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. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Patients experienced care based on the latest updates and learning which followed national updates and safety incidents.

Patients and staff were encouraged and supported to raise concerns, they felt confident that they would be treated with compassion and understanding, and would not be blamed, or treated negatively if they did so. There was a positive culture for incident reporting and learning.

Lessons were learned from safety incidents or complaints, resulting in changes that improve care for others. Staff were aware of changes made following any reported incidents and what and how to report an incident. For example, staff had changed the process for accompanying patients to bathrooms, after an incident where the call bell had been silenced without actions being taken to see why a call had been raised.

Incidents were shared across all teams to enable discussions and learning at a local level. The service had monthly ‘Sharing to Ensure Learning Sessions’ (ShELS). These meetings were recorded with the minutes detailing incidents, their prevalence against national standards and any changes to processes or policies. For example, we saw a review of all ectopic pregnancies reported between January and December 2024. The report gave details of each incident and learning points from each case.

Incidents and complaints were appropriately investigated and reported. All incidents were reviewed by a manager. There were twice weekly incident review group meetings where all incidents within the region were discussed. We saw these reports for the 3 weeks prior to the inspection. We saw actions were taken for learning. Serious incidents were escalated to the event response group, which had a panel of senior clinicians, to review the incident and escalate to a patient safety incident investigation (PSII) if required.

We saw learning from 3 PSII’s which showed areas of good practice, areas for improvement and learning points for sharing. For example, a patient was given intravenous medication instead of their cannula being flushed. No harm was caused to the patient, and they were open and transparent with the patient. Following this they published situation, background, assessment and recommendation (SBAR) for surgical safety and the learning was shared through a ShELS session.

Learning was shared with staff through internal communications and verbal feedback. The team did not have regular meetings where incidents, complaints and learning were discussed. Staff told us they spoke most days informally; however managers would communicate learning formally through email when required. Incident review learnings were shared on the internal communications channel.

There had been 42 incidents between August 2025 and January 2026. The most frequently reported incident related to no appointment available within the required timeframe for urgent post-treatment checks. This was the highest-reported incident type across both the midlands division and the wider organisation. A post-treatment check working group was in place to make improvements.

There was good insight from leaders into the priorities to ensure staff were learning from events. We saw in the quality and risk group meeting minutes from December 2025 the midlands leaders highlighted the growing need to examine near-miss and no-harm incidents more thoroughly. They said current categorisation lacked a dedicated near-miss option, which could mean limiting learning and discourage reporting. This was going to be investigated.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when patients moved between different services.

Safety and continuity of care was a priority throughout a patient’s care journey. This happened through a collaborative, joined-up approach to safety that involved them along with staff and other partners in their care. The service worked with social services and community teams where patients had safeguarding or additional needs to ensure they received safe and appropriate care.

There was a good awareness of the risks to patients across their care journey. The approach to identifying and managing these risks was proactive and effective. The effectiveness of these processes was monitored and managed to keep patients safe. There was a comprehensive initial assessment for all patients which included risk-based questions.

Policies and processes about safety were aligned with other key partners who were involved in the patient’s care journey to enable shared learning and drive improvement. The service was an ‘any qualified provider’ (AQP). This meant they had a contract with the commissioners which widened patient choice and enabled patients to choose the provider that suited them within the contract. They met regularly with other termination of pregnancy providers to share information. They looked at policies together and made sure they were all in line with each other. They also shared learning from incidents when needed and they shared information about patients who were high risk or frequent attenders to ensure they were all sighted on the safety of these patients.

The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving patient’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding concerns were openly discussed at team meetings and briefings. Any identified concerns were recorded during the patient’s initial appointment. It was then highlighted within their record to ensure it wasn’t missed at further appointments. We saw 3 patients with different safeguarding concerns attend on the day of inspection. These were discussed at the safety huddle, and theatre briefing sessions to ensure staff awareness. We also observed staff ask a patient about her safety during pre-admission assessments. This was managed sensitively and confidentially.

All patients were asked three basic safeguarding questions at their initial booking appointment, which was then red, amber, green (RAG) rated. If they were red, it flagged a concern and safeguarding would be investigated in depth. All patients under the age of 18 were automatically flagged to safeguarding.

We reviewed a set of notes for an underage patient who had undergone female genital mutilation when they were younger. The service had supported this patient as they did not want to inform their parents. The service had ensured the patient was first on the list, had an extended recovery period for 4 hours to ensure they were safe and then paid for a taxi to take them home. They also completed a follow-up call to ensure they were recovering well.

Every booking had a safe word that was set up by that patient. When anyone phoned to get access to the booking, they had to pass the security check which was the password.

Staff received training specific for their role on how to recognise and report abuse. Staff received mandatory safeguarding children and adults training. All clinical staff were trained to level 3 safeguarding adults and children, and all non-clinical staff had completed level 2 safeguarding training. Level 3 safeguarding was a bespoke 2-day face-to-face training package mapped in line with the safeguarding intercollegiate document.

Between August 2025 and January 2026, there had been 2 incidents involving delays in safeguarding escalation or follow-up. Safeguarding oversight had been limited due to capacity constraints; however, the safeguarding specialist lead was working to strengthen oversight and provide closer support to teams.

Information about women who had suffered harm or were at risk of harm were appropriately shared with other agencies in a timely way. For example, the local authority were included in conversations about vulnerable women and children. We were told that if a child was unable to attend with a responsible adult, for any reason, their case would be referred to the local multi-agency safeguarding team, and the planned procedure discussed to ensure that risks were known and a joint decision about care could be developed. This ensured that all agencies were aware of individuals risks and enabling further consideration for follow up. Staff told us the referrals were usually picked up and responded to within 48 hours which prevented delays in treatments. We reviewed a set of notes for a 16-year-old who had safeguarding concerns. They had been asked in depth questions to ascertain their level of safeguarding support needed. The patient record was comprehensive. A meeting had been triggered with the safeguarding team as they had not told anyone over the age of 18, they were attending the clinic.

The team saw a high number of at risk and vulnerable patients at the clinic, with around 30% of women attending requiring some form of safeguarding action. The team felt this was higher than other clinics due to the local demographics. In January 2026, a nurse midwife practitioner was appointed with 1 day per week given to review notes and look at safeguarding risks and practices. This included telephoning patients who had been flagged as high risk on the system. This was expected to help the team to prepare and be proactive with managing vulnerable women or those at risk.

There was a clear understanding of the requirements of the Mental Capacity Act (MCA), and staff demonstrate how they put these into practice effectively. We saw that metal capacity was assessed during the woman’s initial assessment and midwives told us that any woman attending whose capacity was uncertain would be referred to an advocate service. Alternatively, if capacity was unclear on the day of treatment, the consultant would complete an assessment prior to any treatment.

The service had access to the Child Protection Information Sharing system, enabling them to share information with partners to better protect vulnerable children.

The service worked with patients to understand and manage risks by thinking holistically. Staff provided care to meet patient’s needs that was safe, supportive and enabled patients to do the things that mattered to them.

Data showed 100% of staff were trained in basic life support and 100% of required clinical staff were trained in immediate life support. The team completed monthly simulation-based education which was a scenario set by the learning and development clinical training team. Themes included anaphylaxis, vasovagal, sepsis and haemorrhage. These were documented and learning was taken from them and actioned.

At our previous inspection, the service did not use a specific paediatric early warning score for children under the age of 16 years undergoing surgical terminations of pregnancy. At this inspection, we found the service had changed the early warning score policy and created a bespoke template for BPAS called Termination of pregnancy Early Warning System (TEWS) including a separate paediatric form.

At our previous inspection, the service did not audit the completion of venous thromboembolism risk assessments and address the findings. Following this, the service had revamped the policy and risk assessment tool. It was embedded into the surgical pathway, and we saw it was completed in all 6 records we checked. It was audited and reported on in the monthly dashboard. Women’s care plans reflected any foreseeable risks and steps were taken to address these. For example, we saw that a woman at risk of thrombosis (blood clot) was given anticoagulant medication (blood thinning) following treatment. The risk and medication were clearly recorded in the clinical notes.

Women were assessed for suitability for discharge following surgical procedures and needed to meet criteria which included an awareness assessment, stable mobility and ensured that they had eaten and drank post procedure. Staff were heard explaining potential side effects of treatments and how and when to escalate concerns. All women were expected to have a chaperone, over 18 years of age for the first 24 hours post-surgical procedure.

Staff used a standardised proforma, which followed the patient’s treatment from initial assessment to discharge. Clinical observations and assessments were clearly recorded throughout the surgical admission, at regular intervals in line with national guidance. For example, clinical observations were recorded on admission as a baseline, during the surgical procedure to monitor the effects of medication and post operatively to monitor recovery. Women receiving misoprostol medication (termination medication) had additional clinical observations were recorded due to the risks associated with administration. These were recorded on a central log confirming a minimum of hourly checks.

We saw patient’s welfare was a priority of the team. They took steps to ensure patients were comfortable, informed and supported during decision making, or treatments. During procedures staff would reassure the patient of time scales and offered hands to hold and words of comfort. We also saw that one woman requested her partner to be in attendance during the procedure, and this was facilitated without any concerns.

De-briefing took place, and we saw staff briefings across all areas of care. There was a safety huddle at the start of each day and the end of theatre lists, when all patients, any risks, and treatments were discussed. There was then a patient brief, before and after procedures covering specifics of each case. These were inclusive of all staff and everyone was encouraged to speak openly.

Staff assessed patient risks appropriately. If a pregnancy was suspected to be outside the uterus, a multidisciplinary team meeting to review scans and discuss the best course of action was completed. We attended one of these meetings and saw that the lead sonographer and clinical lead reviewed scans and confirmed foetal position, and whether it was safe to proceed with the planned treatment. Any pregnancy which was suspected to be ectopic was referred to the nearest acute hospital for emergency treatment. The service had an agreement with the local early pregnancy assessment unit.

There was an abortion-related complications: identification and management policy. If there was an emergency within the clinic, they called 999 and completed life support until the ambulance crew arrived. The ambulance crew would decide which trust they transferred to depending on activity. They had contact details for each service so could inform of pending transfer. They had haemorrhage kits, so women were usually stable prior to transfer. Records showed there had been no reported emergency transfers in the past 12 months.

The service managed patient risks well. There was an ‘outstanding actions’ tab on their online system. This had tasks for the staff to pick up including following up and patients who had called the aftercare line, post treatment calls to patients who had safeguarding needs, and waiting for the outcome from GPs. It was a live view and was checked daily by the staff and outstanding actions were completed.

The service did not operate on anyone over 13 weeks and 6 days pregnant and all treatment was provided under local anaesthetic or conscious sedation. If a patient wanted to have a general anaesthetic, they were referred to another BPAS clinic within the region with the capability to do this.

Sepsis training was covered in mandatory training for all patient facing staff.

The service detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care.

BPAS rented the facilities and were able to request additional space to meet the service needs. The service had several clinic rooms and an office which was used Monday to Friday. Surgical lists were only completed on a Tuesday, and the team requested the minor operations room, recovery and associated waiting area for that day only. Staff told us that these rooms were seldom used by other teams, and therefore they were able to keep their equipment on site.

Other facilities such as staff rest areas, waiting rooms and public toilets were managed by the GP practice. These were suitable for service needs. The Lead Nurse told us, ideally the facility would have a larger recovery area, as the four-trolley area was sometimes too small if women were taking longer to recover from their procedure, which could cause a delay in treatment. All staff felt that the rooms, and facilities were well maintained and ideal for service needs.

Facilities were in line with guidance, with sufficient space for equipment. All rooms met infection control and prevention guidance for clinical areas and were well maintained. Equipment was checked regularly to ensure safety, and we saw daily checks of emergency equipment, fridges and lifts. Compliance was confirmed at the safety briefing prior to commencing the surgical list.

Equipment was available, was suitable, stored securely and used properly. Rooms were locked from 5pm when the GP practice closed and additional locks had been requested to ensure medications, equipment and clinical notes were secured when the service closed at 4pm, however, they had not received these at the time of the inspection. Following the inspection we were told the locks were in place.

Staff used equipment correctly to meet statutory requirements and supported patients to stay safe. We saw that all single use sterile equipment was disposed of safely and all equipment stored was within date.

The provider had an effective approach to assessing and managing the impact of extreme weather events on patients and the service, including flooding. The team completed monthly Simulation Based Education (SBE) which was a scenario set by the learning and development clinical training team. Themes included the disruption of services and saw emergency planning was a regular scenario, enabling exploration of actions. Staff also told us they had recently experienced disruption to the service due to snow and had used some of the learnt processes to manage the service.

The environment did not always lend itself to meet patients’ immediate needs. The clinic was within a GP surgery and although they had rooms along one corridor, one of the rooms was also occupied by a community nursing team. On Tuesdays, the same day as surgery took place at BPAS, they had a baby immunisations clinic. This meant crying babies could be heard when walking past the room and potentially while waiting for a surgical termination. The service had this on their risk register and were aware this could be upsetting for some patients. There had been no local complaints at the time of the inspection. They are unable to change or move this room as the nursing team were there prior to BPAS obtaining the rooms.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met patient’s individual needs.

There were robust recruitment practices to make sure staff were suitably experienced, competent and able to carry out their role. Staff had been employed within the service for a number of years.

There was appropriate staffing levels and skill mix to ensure patients received safe, quality care that met their needs. Records showed adequate staffing, and robust plans for emergency cover.

During the assessment, the team consisted of the nurse lead, a consultant, one midwife and 3 midwife practitioners in theatre. Two midwives in recovery and 2 midwives completing preoperative assessments. The team had a full-time administrator and a visiting Admin Coordinator who attended the centre 2 days per week. There appeared to be sufficient staff to manage the workload on the day of assessment although staff did tell us that staffing was slightly higher than normal because training was taking place.

Staff worked flexibly across all clinical areas, either allocated to clinic rooms, recovery or theatre ensuring competency and skills across the service. They also worked flexibly across the cluster. The Lead Nurse was responsible for 3 clinics (cluster), and staff could move to cover any gaps. There was a cluster midwife on duty during our inspection whose role was to provide support at different centres across the patch, she also held additional skills such as the administration of contraceptive implants. This meant that there was flexibility in cover and appropriate skilled staff available.

Surgeons who attended the clinic were employed under practising privileges. There was a centralised team who ensured all the surgeons had the right checks in place to be safe at work. The service had 2 regular surgeons who worked alternate Tuesdays. Staff had a good relationship with them.

Women experienced continuity of care where possible, if a midwife completed a telephone assessment and was on duty for the planned procedure, they would see the woman for their preoperative appointment.

Staff had the right qualifications, skills, knowledge and experience to deliver safe and effective care. Overall mandatory training compliance was 92%. Staff booked themselves onto courses and received email reminders when their training was running out. Leaders also received alerts about their staff’s mandatory training.

Staff were encouraged to learn new skills and supported with training. Time was given for mandatory training and the team attended regular team/ cluster and national team training. Staff told us that once they had completed their mandated training, they could progress and complete additional training in scanning and contraceptive implants. Training records showed that all midwives were trained to trimester 2, and the midwife practitioners were training for intraoperative scanning. The service had a reduced surgical list 1 Tuesday a month and had training once it had finished.

Staff received training appropriate to their role, service, and this was embedded into practice, with competency assessed. Training was refreshed at regular intervals to maintain knowledge and skills in line with best practice. Staff were given competencies when they started with BPAS, and these were assessed prior to practicing independently. For example, all midwives were trained in trimester 1 scanning on commencement in post. Training was provided by a dedicated sonographer working within the team. Competency frameworks were standardised and related to national standards and legislation. We saw associated assessment tools used to confirm competency.

All staff had an up to date appraisal completed using ‘BPAS perform.’ Managers had undertaken appraisal training and ensured objectives were set and reminders were scheduled throughout the year to ensure the objectives were reviewed and being achieved.

Managers reported monthly to the senior leadership team within their integrated performance report information about staffing, sickness levels and vacancies across the midlands region.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service performed well for cleanliness. The service completed monthly and annual infection prevention and control (IPC) audits. Monthly audits consisted of hand hygiene, uniform, environment and sharps audits. All audits’ results between August 2025 and January 2026 were 100%. The annual IPC audit completed in April 2025 showed 98% compliance. Where there were areas of concern identified, there was an action to improve compliance.

Data showed 100% of staff had completed their infection prevention and control mandatory training.

There were clear roles, responsibilities and procedures around infection prevention and control that met current and relevant national guidance. Roles were allocated at the daily safety huddle and staff knew their roles and responsibility for cleaning and infection prevention.

Staff were provided with and used personal protective equipment (PPE), which met recommended national guidance and was appropriate for the care and risk. Staff wore PPE for all clinical tasks and these were changed between patient contacts. In theatre, equipment was sterile and either cleaned off site or single use for disposal. Equipment such as trolleys and patient couches were cleaned between use. Waste was managed correctly and sharps boxes were closed and clearly labelled.

Foetal remains were stored safely, and staff were seen to be respectful and handled these sensitively. Remains were clearly labelled and stored in line with national guidance and collected the following day for safe disposal.

Women were supported to understand infection risks and were given clear advice before leaving the service. Information was shared relating to signs of infection and actions that should be taken. Staff told us that infection rates were very low due to the nature of the procedures and women standing post procedure.

The service made sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. Staff involved patients in planning, including when changes happened.

Women were supported to make an informed decision about the type of termination appropriate to their stage of pregnancy. Ultrasound scanning was undertaken to confirm gestation for anyone over 9+6 weeks or if gestation was unknown, before medication or treatment was provided.

Women, who could confirm their last menstruation, whose pregnancy was less than 10 weeks were able to have oral medication, “pills by post”. This was the provision of early medical abortion (EMA) medicines being prescribed and taken at home.

Women unable to confirm the date of their last menstrual cycle, were required to attend a clinic to confirm age of pregnancy, prior to being offered any treatment. Women opting for EMA were prescribed medication by a remote prescribing doctor and were able to collect the prescription or take the medication whilst at the centre. Prescriptions were managed centrally and women were added to the “prescribing” pathway, and a remote doctor would review the patients record and prescribe medication.

Women who presented at the clinic, with a confirmed pregnancy of 10 weeks exactly were able to have oral medication on the day and return the following day for the second part of the treatment. This included those who were attending the clinic for scanning to confirm the age of pregnancy. All women with a pregnancy over 10 weeks were required to have a surgical procedure as well as medication. We saw that there were 5 incidents reported between August 2025 and January 2026 relating to medication administration, these were associated with women not taking medication as it had been prescribed at home.

Women could choose pain relief, sedation and local anaesthetic used. The service did not offer general anaesthetic. Discussion about options were clearly recorded and included a safety review. For example, one woman chose to have ibuprofen as pain relief but was noted as having asthma. The midwife checked safety and previous use before administering the medication.

Medicines policies, procedures and systems followed current legislation, professional guidance and relevant best practice so that women’s medicines were ordered, administered, recorded, stored and disposed of safely. Medication administered was kept securely, clearly labelled and disposed of safely. The consultant decided on dose of medication to be administered, and this was clearly recorded at the time of administration.

Controlled drugs, those requiring additional safety checks, were stored, recorded, administered and disposed of safely. Controlled drugs were stored in a suitable locked cupboard within the admin office. On the day of surgical procedures, the medication was transferred into the recovery room by two registered staff, and back to the office at the end of the theatre list. Medications were not left unattended.

Controlled medication was recorded clearly, described the dose given and any wastage. Two signatures were present and there was evidence of regular audits. There were two incidents relating to the safe storage of controlled medicines between August 2025 and January 2026 which included Diazepam not being recorded as a controlled drug, due to staff not knowing the need to record in line with controlled drug legislation. This was corrected once identified as a concern.

Medicines were stored safely within the service but at times it was a challenge to maintain the temperature of the room. Room and fridge temperatures were checked where medicines were stored. Where the medicines were stored, there was no air conditioning. The service mitigated the risks by hiring an air conditioning unit when outside temperatures had risen. This was on their risk register.

Local and national audits relating to the safe storage and use of medicines included, storage, recording use and the use in line with patient group directives. The service achieved greater than 91% across all audits. Issues identified included no controlled drug cupboard in the theatre and medicines not crossed through correctly if written in error. There were associated action plans in place for all audits.

Women were supported to access pain relief and contraception after their surgical procedure. Staff confirmed analgesia prior to discharge and offered contraception implants/ devices. Remote doctors were able to prescribe oral contraception if this was the patients choice.

Women who received conscious sedation were required to be fully awake, able to walk unaided and must have drank something prior to being discharged.

Women given misoprostol were monitored closely and there were additional checks required whilst they were waiting for their surgical procedure. We saw misoprostol check charts were routinely used.