BPAS - Sandwell

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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of patients who used services and wider communities. We checked that leaders proactively 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 requires improvement. At this inspection the rating good. This meant the service was consistently managed and well-led.

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. There was a BPAS 2025 to 2028 strategy for all clinics to follow. The Sandwell strategy was based on the BPAS 6 pillars; our patients, our care, our voice, our finances, research and innovation and out infrastructure. It was basic but was in line with the national strategy. The national strategy had been developed with staff workshops and engagement prior to a board strategy session. The vision for BPAS was by 2030 for BPAS to be the leading provider of equitable, high-quality sexual reproductive healthcare, integrating digital innovation and research driven practices.

The service ensured new starters were on board with the objectives and strategy. All new starters attended an orientation day in the head office.

Staff felt respected, supported, and valued. They were focused on the needs of patients receiving care and worked well together to ensure they achieved good outcomes for patients. Staff were positive and proud to work in the organisation.

Staff and leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and patients using the service and was focused on learning and improvement. Staff told us managers really listened to them and made changes where possible. Staff we spoke with were proud to work for this service and emphasised how good the service was and it was run well. Managers told us the culture in the clinic was “very open and transparent” and the team were ‘brilliant.’ The Treatment Unit Manager and Lead Nurse worked well together as an established team.

Leaders put patients safety at the centre of their priorities. We saw in the quality and risk group meeting in December 2025 patient safety priorities for 2026 to 2027 were discussed. Leaders wanted to streamline the priories based on incident data and thematic reviews. This would feed into the patient safety response policy and programme launch.

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 experience, capacity, capability and integrity to ensure the organisational vision could be delivered, and risks were well managed. The service was run by a triumvirate which consisted of a Regional Clinical Lead, Operations Manager and Quality Matron. The service was managed by a Treatment Unit Manager and Lead NurseNurse. All managers had completed BPAS leadership training. The provider had recently brought in new online leadership master classes which the manager was completing. The Treatment Unit Manager told us there was great progression and progression planning for staff. Managers told us they felt supported in their roles and felt there were good escalation channels to the senior leadership team.

Leaders at every level were visible and led by example, modelling inclusive behaviours. Staff told us leaders were approachable and supportive. Members of the senior leadership team were visible, and staff told us they listened to staff. Staff gave us examples of things they had highlighted to the senior leadership team which had subsequently changed for the better. Staff felt the leaders gave them a voice and staff were grateful for this.

There were processes for providing all staff at every level with the development they needed, including high quality yearly appraisals and career development conversations.

Leaders were knowledgeable about issues and priorities for the quality of services and could access appropriate support and development in their role.

Leaders held staff meetings where staff told us they could voice their views and were listened to and valued.

Senior managers attended regional meetings with the senior leadership team where they received updates, discussed governance, performance and shared learning.

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

Staff and leaders acted with openness, honesty and transparency.

Staff and leaders actively promoted staff empowerment to drive improvement. They encouraged staff to raise concerns and promoted the value of doing so. All staff were confident their voices would be heard.

All staff had completed freedom to speak up mandatory training and all managers had completed specific training for managers called ‘Freedom to Speak Up – Listen Up.’

There was a culture of speaking up where staff actively raised concerns and those who did were supported, without fear of detriment. Staff we spoke with felt able to raise concerns without fear. Staff told us managers acted on concerns raised.

There was a freedom to speak up guardian for the service where staff could raise concerns anonymously.

Senior leaders also held an all staff conference for 2 hours every quarter where anonymous questions could be posted and these were all answered; staff told us they felt included and able to speak up.

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

There was an equality and diversity policy. Equity and diversity training was part of staff’s mandatory training programme; 100% of staff had completed this.

The service completed an equality impact assessment for each new policy to ensure their policies, practices and decision making processes were fair and did not present barriers to participation or disadvantage and protected groups from participation.

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

There were clear and effective governance, management and accountability arrangements. Staff understood their role and responsibilities. Managers could account for the actions, behaviours and performance of staff. There was a well-led and effective clinical governance structure with clear systems and processes. The triumvirate supported the service’s managers with compliance.

Information was reviewed monthly and quarterly from their risk and patient management systems to identify trends in patient outcomes and clinical quality that needed addressing. Performance dashboards, the local clinical audit compliance board (LCACB), were used to discuss, benchmark and monitor performance at monthly senior management team meetings and were accessible to Treatment Unit Managers to review and compare their performance against other treatment centres. We reviewed the midlands LCACB for October, November and December 2025. Sandwell compared favourably to the other units within the midlands with compliance only dipping below 96% for consent audits results; all other audits were above 96% for the 3 months. There was an action plan associated with any concerns with the audits.

Sandwell unit had an operational compliance dashboard which the managers used to monitor training, complaints, risk, and quality assurance. There was a rolling action plan which was kept up to date. We saw all actions had been completed at the time of the inspection.

There was an assurance framework which included regular meetings where managers reported to senior management on a regular basis. The Quality Matron did regular assurance checks on the clinic. The managers also presented an integrated performance report to the senior leadership teams.

The service undertook a monthly quality and risk group which included actions from previous meetings, policy updates, audits, quality assurance reports, and patient safety priorities.

The service took additional steps to ensure good governance and compliance by undertaking annual peer reviews (mock CQC inspections). The service had had this undertaken in the summer 2025 with minimal improvements needed.

The service had effective systems, such as audits and risk assessments, to monitor the quality and safety of the service. There was a comprehensive audit schedule of clinical and non-clinical audits.

The service had a joint risk register with their region. Risks were rated red, amber and green depending on the level of risk, to identify the highest risks. Measure and controls to manage the risks were recorded and review dates were noted to ensure risks were monitored. Each risk was identified as being reviewed or approved and was rated as green or amber. There were 2 risks which were related to Sandwell clinic. These were:

• Patients sit in a shared waiting area with mothers and babies waiting for baby clinic and pregnant women waiting to see a midwife.
• Lateness of patients.

Measures were in place to reduce these risks and their risk rating remained low. We saw risks had closed in 2025 for example, surgical staffing as the Lead Nurse was consistently in the numbers. It had closed as recruitment had been agreed for 15 hours.

The Treatment Unit Manager cascaded information to their teams by daily conversations, information disseminated by the communication channel and team meetings and updated them with latest issues, developments. Learning from incidents, complaints and changes in policies and procedures were also shared.

Staff told us they were sent communications regarding any updates in policy and audit results. Team meetings occurred, but these were not frequent. We saw 2 had occurred in 2025 and discussions were brief. Neither discussed audit results, risks within the clinic, updates in policy or any feedback from the governance meetings. Managers told us they sat down as a team daily and looked at their lists and had informal discussions about audits results and learning.

Data or notifications are consistently submitted to external organisations as required. There were effective governance arrangements to demonstrate compliance with the Abortion Act 1967. There were processes to ensure that the certificate of opinion (HSA1) and abortion notification (HSA4) were completed in line with legislation. All 6 records we reviewed confirmed this had been completed.

There were robust arrangements for the availability, integrity and confidentiality of data, records and data management systems. Information was used effectively to monitor and improve the quality of care.

At our previous inspection, we found the service was in breach of regulations relating to good governance. At this inspection, these issues had been resolved.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for patients. Staff share information and learning with partners and collaborate for improvement.

The service worked alongside other termination of pregnancy services as they were an ‘any qualified provider’ (AQP). This meant they had a contract with the commissioners which widened patient choice and enabled them to choose the provider that suited them within the contract. They met regularly with other termination of pregnancy providers to share information, including information to safeguard vulnerable patients.

The service leaders met with the integrated care board (ICB) and presented data to them regarding patient outcomes. They had started a joint termination of pregnancy provider/sexual health action plan alongside other services within the AQP. This group was formed by the ICB in June 2025 and included public health representatives from each provider. This group was established to ensure delivery against national guidance, looking at the recent abortion commissioning guidance and performance and quality metrics. We saw the action plan was regularly updated.

BPAS worked alongside other advocacy charities and networks to champion reproductive choice and advance improvements in legislation. They also regularly collaborate with organisations dedicated to public health, human rights, and community wellbeing.

Managers from BPAS attended a quarterly health exploitation meeting which linked in with the ICB, local trust and other healthcare providers in the area who worked with young patients.

BPAS were also a member of the teenage pregnancy delivery group which aimed to bring together collaboration of partners that each contribute to preventing teenage conception and facilitate a collaborative approach to deliver and monitor the actions and outcomes of the teenage prevention and reduction strategy for the area.

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

Staff and leaders had a good understanding of how to make improvement happen. The approach was consistent and included measuring outcomes and impact. Examples of learning were shared across the organisation. For example, the service completed a thematic review of postpartum haemorrhage as 5 cases between December 2024 and February 2025 had required a transfer into the NHS for care. Learning was shared across the teams following the review.

There were processes to ensure that learning happened when things went wrong, and from examples of good practice. Leaders encouraged reflection and collective problem-solving.

Staff were supported to prioritise time to develop their skills around improvement and innovation. There was a clear strategy for how to develop these capabilities and staff are consistently encouraged to contribute to improvement initiatives. BPAS had a 2025 to 2030 integrated research and innovation strategy. There was a clear vision of meeting their 4 key priorities and ensuring that BPAS was responsive to the needs of patients, staff and the wider abortion care sector. There was an ongoing discussion at the patient’s forum regarding a research project which was in progress around looking at the potential benefits of artificial intelligence in the patient pathways. The provider participated in regular research to improve the outcomes for patients.

Leaders encouraged staff to speak up with ideas for improvement and innovation and actively invest time to listen and engage. There is a strong sense of trust between leadership and staff. The patients forum and the staff conference encouraged ideas and ensured staff were involved in shaping the future of the service.

The provider completed in depth reviews of patient outcomes and shared learning with staff. Leaders completed Sharing to Ensure Learning Sessions (ShELS) and learning was shared with staff. We reviewed a ShELS for January 2026 which showed a thematic review had been undertaken into ectopic pregnancy identified following early medical abortion with no ultrasound scan prior to treatment. This was undertaken to provide assurance of safety for the pills by post (no scan pathway). Data showed 0.09% of cases had an ectopic pregnancy and 38% of these had no identifiable risk factors. The review assured the service that the BPAS triage process was safe and effective and no changes were needed to the pathway.

The provider had an ongoing patient pathway transformation programme which was focusing on improve the care for 1 in 10 patients who require additional support during their treatment. They were establishing a clinically-led, multidisciplinary coordinated care team who would provide robust communication and coordination throughout each patients journey at BPAS, offering a single point of contact and ensuring a seamless care pathway. There was a 12 month pilot project ongoing at the time of the inspection.