We spoke with the registered manager, care coordinator, nurse and four people attending the clinic on the day of our inspection.

People’s choices were respected. Staff took steps to ensure that people were presented with all the options available to them. One person said “I have asked lots of questions, the staff could not have been more helpful”.

People had a full explanation of the treatment they had chosen. The provider took steps to ensure that people gave informed consent before treatment commenced.

Care and treatment was delivered with people’s safety and welfare in mind. Current health conditions and medical history were checked to ensure that the chosen treatment was safe. Treatment was signed off by two doctors in line with current legislation. There were processes in place to deal with foreseeable emergencies.

Staff had a good understanding and awareness of safeguarding issues. The provider had strict processes in place to ensure that potential abuse was identified.

The provider had a detailed current complaints policy. People were aware of how to make a complaint and written information was available in various formats.

We spoke to five people who said that the staff were friendly and that they felt that they had the information they required to make an informed decision about the treatment they required. One person said "The staff here are very friendly and discreet." Another person said " I would definitely tell my friends to come here as the staff are lovely." We saw that the welfare of the women attending the clinic was ensured through having staff that were knowledgeable about the procedures, the medications and equipment used.

There were effective systems in place to reduce the risk and spread of infection.The clinic was clean and free from odours. A cleaning schedule was clearly displayed and cleaning was monitored by the clinic manager. Regular audits took place which showed 100% adherence to the standards used at the clinic.

Staff received appropriate professional development as there was access to both e-learning and classroom based learning. Staff undertook appropriate training in order to provide safe care. There were sufficient numbers of staff on duty at the time of the inspection to meet the care and welfare needs of the women in attendance.

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others. The clinic undertook a number of audits each month which were used to enhance the service provided.

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 treatment for the termination of pregnancy was not commenced unless two certificated opinions from doctors had been obtained.

Women who used the service at BPAS Swindon told us that the staff were sensitive and sympathetic. They said that they did not feel pressurised, questioned or judged and that staff took time to provide very clear explanations of options and treatments available. One woman said that the way she was treated at BPAS Swindon “made a bad experience bearable” and she was grateful that she was able to make appointments that were convenient to her. Women felt that their privacy and dignity were respected and they were treated with courtesy. The environment was described as “relaxed” and “nice and private”.

The British Pregnancy Advisory Service (BPAS) Swindon opened in 2004 providing a termination of pregnancy service. This included a satellite service in Bath which provides diagnostic and screening tests and counselling. BPAS Swindon provided the management and nursing staff for the Bath satellite service. Both services are provided under a contract with Swindon and Wiltshire area Clinical Commissioning Group (CCG). BPAS Swindon maintains a lease of a suite of ground floor rooms which were used solely by the service.

BPAS Swindon provides a range of information, support, diagnostic and screening services, emotional support and aftercare. All of these relate to fertility and associated sexual health needs. This included; pregnancy testing, emotional support, miscarriage management, sexually transmitted disease testing and contraceptive advice and treatment. The main activity was termination of pregnancy. Early medical abortion (EMA) treatments were provided up to nine weeks gestation and medical abortions were provided up to 10 weeks gestation. Surgical terminations under local anaesthetic only were provided up to 12 weeks gestation. The Bath satellite service provided only assessments and consultations (no treatments).

We carried out this comprehensive inspection as part of the first wave of inspection of services which provided a termination of pregnancy. The inspection was conducted using the Care Quality Commission’s new methodology for services of this type. We have not provided ratings for this service. We have not rated this service because we do not currently have a legal duty to rate this type of service or the regulated activities which it provides.

An announced inspection of BPAS Swindon took place on 26 and 27 May 2016. The Bath satellite service was not visited as part of this inspection. We inspected five core areas to review if the services provided were safe, effective, caring, responsive and well led.

Our key findings were as follows:

Are services safe at this service

By safe, we mean people are protected from abuse and avoidable harm.

• Staff were encouraged to report incidents and received feedback regarding action plans and learning. There was evidence learning was shared as a result of incidents locally and from other BPAS throughout the whole organisation.
• The environment and equipment appeared visibly clean and the risks of patients contracting an infection were low.
• Sufficient equipment was in place to deliver the service and equipment was monitored to ensure it was safe for use.
• Procedures were followed for the safe management of medicines.
• Systems were in place which showed the information was safely processed and documented in records.
• Staff demonstrated an understanding of the signs of abuse and understood their responsibilities and what processes to follow. All staff providing direct care to vulnerable patients and those aged under 18 years had received appropriate safeguarding training.
• Processes were in place to ensure patients received safe and appropriate care, risks were assessed and appropriate actions taken.
• Staff completed the World Health Organisation Five Steps to Safer Surgery checklist for all surgical procedures.
• There was sufficient staff to provide safe patient care

Are services effective at this service.

By effective, we mean care, treatment and support achieves good outcomes and is based on the best-available evidence

• Patients had their needs assessed and care and treatment provided which was evidence based following national standards, policy and law.
• BPAS Swindon participated in audit and research programmes. This enabled the service to evaluate if treatment and care was being provided in line with national standards and to identify improvement actions.
• The effectiveness of treatments was kept under regular review and appropriate actions were taken when required.
• Records showed patients had their pain assessed. We observed patients were provided with appropriate medicines and information about their use and potential side effects.
• Audits showed patients had treatments promptly and processes were in place to minimise delays.
• Whilst we observed nurses discussed the risks of each treatment option with patients, this was not documented in records as being completed.
• The nursing staff and manager demonstrated an understanding of their responsibilities regarding the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards. Staff followed policy and procedure regarding the consent of patients and this was evidenced in care records.
• Staff had been supported in their roles and to maintain and develop their clinical skills and competencies.

Are services caring at this service

By caring, we mean staff include patients in all aspects of their care and treat patients with compassion, dignity and respect.

• Between January 2015 and September 2015, between 99% and 100% of the 67 respondents of a patient survey said they would recommend BPAS Swindon. This was a higher (better than) ratio compared to similar NHS services.
• Patient feedback was consistently positive regarding being treated kindly, and with compassion, dignity and respect.
• We observed patients’ individual emotional needs were supported by staff who provided impartial, non-judgemental support and advice.

Are services responsive at this hospital/service

By responsive, we mean services are organised so they meet people’s needs

• BPAS had a telephone service, accessible 24 hours a day, seven days per week which provided a triage and booking system. BPAS Swindon had consistently provided timely access to services. The majority of patients within a 30 mile radius of the service had their treatment within seven days from calling for an appointment.
• The majority of patients, who had termination treatment, received this when they were less than 10 weeks in gestation. This was higher (better than) the national average (Office of National Statistics, June 2015).
• The BPAS Swindon service and the national website contained a wide range of information and resources which were adaptable to meet different needs. These included: British sign language videos, web chat and telephone services and written information which was available in 19 languages.
• Processes were in place to gather patient feedback. The complaints policy and procedure was understood and followed and complaints across the organisation were shared for quality improvements and learning.
• The facilities provided for monitoring patients’ pre and post-surgical procedures. The designated area was small and privacy and dignity between patients could have been compromised.
• Patients’ were not informed that if therapeutic counselling was required, BPAS would refer patients on to external services who had appropriately trained (Diploma level) pregnancy counsellors.
• There was no audit to evidence that those patients who exceeded 10 working days from referral to treatment was related to patient choice.

Are services well led at this hospital/service

By well-led, we mean the leadership, management and governance of the organisation assure the following: the delivery of high-quality person-centred treatment and care, supporting staff learning and innovation, and promoting an open and fair culture.

• BPAS Swindon had been granted a licence from the Secretary of State to provide termination services. This was in date and displayed at the clinic.
• Processes and systems were in place to link and monitor governance information from the BPAS board to BPAS Swindon and vice versa.
• Quality and risk management information were reviewed for service and patient safety improvements. Any necessary action plans were put in place and learning was provided to staff.
• Senior staff were experienced and staff spoke positively about leadership and BPAS as an organisation. Staff said there was an open culture and they felt supported in their roles.

However, there were areas of practice where the provider needs to make improvements.

The provider should:

• BPAS should advise patients’ that staff only provide impartial, non-directive advice and are trained as counsellors but not to a Diploma level. Therefore, if therapeutic counselling was required, BPAS would refer patients on to external services who had appropriately trained pregnancy counsellors.
• BPAS should audit those patients who exceed 10 working days from referral to treatment. This would provide evidence if the reasons for this were related to patient choice.
• BPAS should evaluate how they evidence discussions with patients have been completed regarding treatments and any associated risks.
• BPAS Swindon should review the facilities provided for monitoring patients’ pre and post-surgical procedures. The designated area was small and privacy and dignity between patients could have been compromised.

Professor Sir Mike Richards

Chief Inspector of Hospitals