We carried out an inspection in December 2013 and made a compliance action about the clinic’s support for staff and its arrangements for appropriate training, supervision and appraisal. We carried out an unannounced inspection on 27 August 2014 to check on the actions the provider had taken to meet this compliance action.

We found that the provider had made improvements since our previous inspection. We spoke with the registered manager who showed us training logs that were now kept to record mandatory and other training. We saw that staff appraisals had been undertaken and recorded in staff files.

In response to information we had received from an external organisation, we also looked at arrangements for monitoring the quality of the service provided and following up clinical incidents. We considered there was room for strengthening these arrangements.

We did not speak to women attending the clinic on this occasion.

We spoke with six people who had used the service. One person said "The staff introduced themselves by name which made me feel more at ease". We asked how the care and welfare of people using the service was managed. One staff member explained "I try to make people's short experience with us here as comfortable as possible".

We talked with staff to understand how the service worked with other providers. Staff told us that they liaised with a variety of other service providers including general practitioners, ambulance services, counsellors, social workers and interpreters.

The clinic displayed information to help people protect themselves from abuse and provided written information on where to go for help and how to report abuse.

We reviewed three staff records to check that the provider had effective recruitment and selection processes. We checked that employees were judged suitably qualified, skilled, experienced and of good character before they were employed.

Not all staff we spoke with were able to recall when they had last attended a training event or when they had last received learning and development. We asked further questions and prompted three staff but they were unable to provide any clear details.

We saw literature and information on display for people to provide their comments, complaints and feedback. The provider may wish to note that there was a lack of monitoring and audit for this and some other aspects of the service.

We spoke with three people using the service and several staff. People using the service told us that they had received good care, support and treatment. One person said "I had to sign a consent form and the treatment was fully explained". Someone else told us "staff were thoughtful and respectful to me", while another commented on the care they had received, "staff were kind and sensitive during my stay".

We looked at records and found that these were being completed and stored effectively and care and treatment was being fully recorded. We looked at people's journey through the clinic at all stages and found that staff were available to support people at each stage of their care. Staff were well organised and rooms offered relevant information and privacy to people receiving treatments.

We looked at how the clinic was kept clean and checked cleaning schedules and domestic rotas. Clinical staff understood the importance of infection control and were aware of their responsibilities to cleanliness and hygiene. There were policies to support this and we noted that the clinic supplied ample hand hygiene resources in each room.

We spoke with staff about their training and clinical updates and staff confirmed that they received regular training to support their roles. We looked at training schedules of several staff and found that they had attended a range of training and development days, including one on Information Governance.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We did not speak directly to the people who were using the service on the day of our visit, but we asked them if they would answer some written questions about the service following their treatment there. Some people responded and told us what they thought. They said that the staff were kind and supportive and had explained about their treatment in a clear way. They said that they felt listened to and were able to make choices about their care and treatment.

BPAS ask everyone who uses the service to complete a survey about their experiences. The feedback from these indicates that the majority of people are happy with the service.

British Pregnancy Advisory Service (BPAS) provides a termination of pregnancy service in Richmond, Surrey. The service

is provided from a building owned by the service and there is a satellite clinic giving advice on pregnancy options, in Willesden, North London.

BPAS Richmond offers advice to women and teenagers and the full range of abortion procedures from early medical abortion procedures up to a gestation period of ten weeks and surgical abortion procedures up to a gestation period of 24 weeks (the legal limit for most cases). Contraception for women is also offered.

Our key findings were as follows:

Safe

• Some aspects of safety required improvement. Serious incidents were reported and investigated. BPAS reviewed these centrally, rather than at clinic level. The cascade of learning and actions required as a result of incidents was not always timely. In more serious incidents when women had to be transferred to hospital, the clinic had not always involved hospital staff at an early enough stage, which was a potential risk to women.
• Lower level incidents, broken equipment, misleading signage, the use of supernumerary staff to cover staff shortage were not routinely reported.
• Although medicines were appropriately stored, we had concerns about the BPAS policy of using the content of a single ampoule of propofol for more than one patient, which was outside the licence for that drug. 
• Staff were aware of safeguarding procedures and had received training in safeguarding adults and children. However, safeguarding policies did not reflect all up to date national guidance on sexual exploitation of children and young people and risks of female genital mutilation.
• The environment and equipment were generally clean and well maintained, and infection control procedures were mostly followed, but there was room for improvement here.
• The clinic was adequately staffed with doctors, nurses and healthcare assistants. Nursing staff shortfalls on shifts were covered by supernumerary senior nurses or by temporary bank and agency nurses.

Effective

• Women were cared for by a team of sufficiently trained doctors, nurses and administrative staff to provide care to women that protected them from abuse and avoidable harm, which was in line with Department of Health's  Required Standard Operating Procedures.
• There was a programme of auditing determined by senior managers based at the provider’s head office. However, sampling for audits was not proportionate to the size of the clinic.

Caring

• Women received compassionate care,and were treated with dignity.
• All women considering termination of pregnancy had access to advice on abortion options and contraception.
• Clinic staff were sensitive to the different stages of decision-making that individual women had reached. Assistance was tailored to their age, comprehension and social circumstances.

Responsive

• Bookings could be made through a central BPAS booking line at any time of day or night.
• An independent telephone interpreting service was available to enable staff to communicate with women who did not speak English.
• Staff monitored the performance of the clinic against the waiting time guidelines set by the Department of Health and it was performing satisfactorily.
• Feedback was sought from women, and surveys and complaints were used to identify areas for improvement.
• Women at later gestation periods were able to decide on disposal arrangements for the pregnancy remains, and their wishes and beliefs were respected, however the issue was not raised by clinic staff for women at earlier gestations. All women should have this opportunity. A 24-hour advice line was available for women if they had concerns following an abortion.

Well-led

• Staff at the clinic were well supported by managers based at the provider’s head office and by regional managers. However, the leadership on site was an area for improvement. Medical, nursing and administrative staff worked in separate hierarchies and information flows were not always good, and there was no overall staff leadership.
• BPAS had not provided training for the registered manager in the legal responsibilities of the role. Staff understanding of legal obligations was weak; for example the Department of Health license was not displayed prominently within the clinic to assure women of the appropriate registration of the service.
• The culture within the service was caring, non-judgemental and supportive to women, but we saw evidence that staff did not always work well together among themselves. A clique of staff who had worked together for a long time were not always supportive to new staff.
• Staff spoke positively about the need for and value of the service offered to women.

There were areas of poor practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure all staff understand and follow protocols for transfer to NHS hospitals in the event of serious incidents.
• Comply with the practice recommended by the product manufacturer, NHS England and the Royal College of Anaesthetists and discontinue multi-dosing from single patient use propofol ampoules.

In addition, the provider should:

• Display the certificate of approval (issued by the Department of Health) in a prominent position within the clinic to help women and clinicians better understand the licensing system.

• Review safeguarding policies regularly to ensure they reflect all up-to-date guidance, including on the sexual exploitation of children and young people and risks of female genital mutilation.
• Review the policy on disposal of pregnancy remains following pregnancy loss or termination in the light of the Human Tissue Authority's 'Guidance on the disposal of pregnancy remains following pregnancy loss or termination' March 2015.
• Ensure incidents of all kinds, including those with a potential to cause harm to women or staff, even when no harm occurred, are reported and that local staff receive prompt feedback to reduce the risk of recurrence of incidents.

• Encourage greater local ownership among staff of practices and procedures at the clinic, including carrying out audits that are proportionate to the size of the clinic, assessing local risks and encouraging staff to take responsibility for maintaining standards.
• Ensure there is a clear referral pathway for appropriate women to trained counsellors with appropriate expertise if such staff are not available at the clinic.
• Monitor waiting times systematically for women attending the clinic to help identify ways of improving the experience for women.

Professor Sir Mike Richards

Chief Inspector of Hospitals