• There were processes in place to report and investigate incidents; all staff we spoke with understood their roles and responsibilities in relation to reporting incidents. Lessons learned were shared amongst staff to prevent further occurrences.
• Staff were trained in safeguarding adults and children and understood how to recognise and report concerns. Staff were able to demonstrate their understanding of female genital mutilation and sexual exploitation.
• The assessment, treatment and recovery rooms were all visibly clean. Hand hygiene protocols were followed and we observed all clinical staff adhering to bare below elbows guidelines. Monthly hand hygiene audits were carried out and showed a high level of compliance. However, whilst observing staff on the announced, we noted that staff did not wash their hands between patients.
• Medicines were securely stored and were placed in fridges. All medicines we checked were in date and staff followed systems for checking orders and deliveries.
• Records we reviewed were clear and legible. Audit results showed compliance against the BPAS record criteria. Records were securely kept on the premises for four months and then were couriered to BPAS Head Office.
• Patients were clinically assessed to make sure they were medically suitable for an abortion. This involved reviewing their medical history and checking their blood group as well as vital signs.
• The service provided care and treatment that took account of best practice policies and evidence based guidelines including standards set by the Royal College of Obstetricians and Gynaecologists (RCOG) guidance and the Required Standard Operating Procedures (RSOP) guidance from the Department of Health.
• Staff provided appropriate pain relief and advice pre and post procedures.
• Staff had received training in specialist areas such as scanning and consent to treatment. All staff had received an appraisal in the last 12 months.
• The staff provided compassionate care to patients and treated them with kindness, dignity and respect. Staff were non – judgemental and provided patients with a number of options in order to make a decision about any treatment. Feedback from patients showed that 100% would recommend the service to someone who needed similar care.
• All patients were seen by a BPAS member of staff individually prior to consultations and then could be accompanied by a friend or relative if preferred. The Client Care Coordinator was not trained to diploma level in counselling, as recommended in the RSOP 14. However, they had undergone a BPAS training programme which included theory and competency based assessments. Staff who were involved in counselling, including midwives, nurses and client care coordinators had undertaken the BPAS patient support skills and counselling and self-awareness course.
• Patients were referred by a number of routes that included G.P‘s, hospitals and self – referral and were able to book appointments 24 hours a day, seven days a week. Medical and surgical procedures were available for patients up to 12 weeks and six days gestation. For later gestations, patients were offered treatment at other sites of BPAS,
• Data provided by the clinic showed patients were not always seen within RCOG recommended timeframes. The reasons for delays or extended waiting times were not given but it was possible that these delays were due to patient choice.
• Information leaflets and booklets were provided to patients and sections of the BPAS guide explained in detail. Patients had access to a 24 hour helpline, seven days a week for advice post procedure.
• There were systems in place to support patients when making a complaint. Complaints about the service were resolved in a timely manner and information about complaints were shared with staff to aid learning.
• Staff were aware of the BPAS vision and were supported to follow the corporate strategy. Staff were able to demonstrate common aims during individual interviews and described ways of working as a team. Local leadership was evident and lines of accountability were clear. Staff felt senior managers were visible and available for further advice. The Registered Manager had a good understanding of the service, its risks and actions needed to improve the service they delivered to patients.
• Risk management arrangements were in place to make sure that the certificate(s) of opinion HSA1 were signed by two medical practitioners in line with regulatory requirements.
• HSA4 forms were submitted electronically to the Department of Health within 14 days of the termination.
• The mandatory training record provided by the Registered Manager showed a record of staff designation and when training was overdue

However;

• We reviewed fridge temperature recording sheets and found seven omissions in daily checks.
• The service did not follow best practice guidance in relation to the simultaneous administration of abortifacient medication (medicines used to bring about abortion) for early medical abortions. BPAS introduced simultaneous administration of abortifacient medications in March 2015. This is not in line with RCOG guidance but a structured approach had been taken when planning and implementing this pathway and it was kept under regular review.
• Screening for chlamydia was offered to all patients under the age of 25 years old and also as required by NHS Clinical commissioning groups. This was not in line with RSOP 13 which states that “all women should be offered testing for chlamydia, offered a risk assessment and tested as appropriate” (Department of Health, page 26).
• Patients were not informed about the statutory requirement of HSA4 forms; Staff did not explain to patients that these details were sent to the Department of Health and that it was a legal requirement.
• The clinic was not accessible for patients with reduced mobility; patients would be directed to another site if required.
• There was no local risk register or other document that identified local risks and the control measures in place but the provider had recently employed a risk management and client safety lead who was working with Registered Managers nationally to implement systems such as a local risk register and improved incident reporting systems (including the implementation of an electronic reporting system).