We visited the main Birmingham clinic but we did not visit the satellite clinic, this had been providing services for only a few weeks at the time of our inspection. During our visit we asked the nursing staff to notify people using the service that we were visiting and would be happy to speak to them. Three people agreed to speak with us about their views of the service they had received. They told us they were satisfied with the service they had received. One person told us “I wasn’t very happy before I came here today, I was very nervous and distressed but now I feel relieved”.

People who used the service were given appropriate information to help them understand their treatment. Before people received care or treatment they were asked for their consent.

The provider had an effective system in place to continuously monitor the quality of the service. We found that the systems for record keeping and managing medicines had improved since our last visit.

During our visit we spoke with six members of staff in addition to the registered manager. During our visit we asked the nursing staff to notify people using the service that we were visiting and would be happy to speak to them. Two people agreed to speak with us about their views of the service they had received. People using the service told us that they were happy with the care they received at the clinic. They told us that their care and support needs were being met.

People told us that staff explained their care, treatment and support choices to them. This meant that they had the opportunity to be involved in making decisions about their care. A person using the service told us ‘’The doctor talked me through all the treatment options.’’

We found that the systems for record keeping and managing medicines were not sufficiently robust and improvements were needed.

We found that the systems for monitoring the service to ensure that people received a quality service were satisfactory.

Marie Stopes International became the registered provider for this clinic in June 2012. During our inspection, we asked the commissioning team at the local primary care trust about the quality of the service the clinic provided. They did not have any information to share with us about the quality aspects of the service.

Marie Stopes International (MSI) Birmingham Centre is operated by Marie Stopes International, a not for profit organisation that was founded in 1976 to provide a safe, legal abortion service following the Abortion Act 1967.

MSI registered the Birmingham Centre with the Care Quality Commission (CQC) in July 2012.

MSI provides regulated activities at the Birmingham Centre and at seven other associated locations known as satellite clinics that provide early medical abortion. These are Central Birmingham Early Medical Unit (EMU), Sparkhill EMU, Erdington EMU, Walsall EMU, Wolverhampton EMU, Stourbridge EMU and Handsworth EMU.

MSI Birmingham Centre provides surgical termination of pregnancy procedures up to 23 weeks and six days along with medical termination of pregnancy and early medical termination of pregnancy up to nine weeks plus four days gestation. Surgical termination of pregnancy is available under conscious sedation, under general anaesthetic or no anaesthetic according to patient choice and needs. The service also provides family planning services, including advice on contraceptive options. The service provides oral contraception and long acting reversible contraception (LARC) as well as male sterilisation (vasectomy).

MSI Birmingham Centre provides services to adults and young people above the age of 15 years.

We had previously inspected MSI Birmingham Centre in June 2016 where we highlighted a number of concerns. We have had on-going contact with the provider since that time about the implementation of its quality improvement plan. We carried out this inspection to follow up on those concerns and to assess the improvements made by the provider.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key questions. We regulate termination of pregnancy services but we do not currently have a legal duty to rate them. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

Since our last inspection in June 2016, we have noted the following improvements:

• A new electronic system for incident reporting
• The introduction and monitoring of surgical safety checklists
• The introduction of Termination Early Warning Scores (TEWS) used to detect deteriorating patients. However this was not yet embedded at the time of inspection.

We found the following areas of good practice:

• There was an electronic incident reporting system in place to report incidents. Staff had received training in its use.
• All MSI Birmingham Centre staff were trained to the appropriate safeguarding level. We saw good awareness and recognition of adult safeguarding, children’s safeguarding, child sexual exploitation (CSE), and female genital mutilation (FGM).
• Mandatory training was provided in a range of topics, and management had the systems in place to monitor compliance.
• Checklists were undertaken for all patients undergoing surgical procedures.
• Patient records were accurate, complete, legible, up to date and stored securely. This was in line with the Data Protection Act, 1998.
• Learning and development was provided at an appropriate level to enable staff to develop and maintain their skills and competencies in areas such as consent and scanning.
• The clinic managed treatment in accordance with relevant, current, evidence based guidance such as Royal College of Obstetricians and Gynaecologists (RCOG) and National Institute of Health and Care Excellence (NICE).
• Pain was assessed and treated in accordance with national guidelines.
• We saw good multi-disciplinary teamwork in the clinic.
• We observed staff treating patients in a non-judgmental, non-directive and supportive manner.
• Patient satisfaction survey scores were consistently high.
• Marie Stopes offered private telephone counselling for patients.This included issues such as miscarriage or ectopic pregnancy.
• Staff had access to telephone translation services for patients whose first language was not English.
• Staff discussed treatment options depending on the patient’s individual circumstances, needs and gestation.
• The layout of the building did not support access to patients with physical disabilities. Therefore, staff were able to redirect disabled patients to an alternative clinic.
• There were clear patient pathways for surgical and medical patients that eased the flow of patients through the clinic.
• Between April 2016 and March 2017, all patients were offered an appointment in less than five working days from the decision to proceed.All patients had a procedure less than 10 working days from their first attendance. This was in line with RCOG guidance.
• Staff were committed to the organisation’s vision of parenthood choice and women being in control of their own fertility. The organisation had developed a ‘Future Fit’ vision, although staff at the clinic did not refer to it.
• Appropriate protocols were in place to comply with the Abortion Act (1967).The Department of Health licence requirements and Royal College of Gynaecologists recommendations for good practice.
• There was an appropriate system in place to ensure HSA1 and HSA4forms were completed.
• The provider organisation had identified the need for the service at the clinic to undergo a ‘supportive peer review’. It had begun to take urgent action just before our inspection visit to mitigate risks identified by this review.
• The provider was taking action to reconfigure the management and governance arrangements to support the service.

However, we also found the following issues that the service provider needs to improve:

• Staff incident report training was below the provider’s target. Staff told us they did not receive feedback either on an individual or group basis, therefore the systems in place to report incidents and learn from them, were not effective.
• Compliance with training targets was not achieved; however, this was due to the high level of new starters in the clinic.
• Some aspects of infection control needed improvement. For example, we found equipment to be dusty in both the day care room and treatment room.
• We observed that clinical staff did not always decontaminate their hands immediately before or after every episode of direct contact or care in line with the World Health Organisation five moments of hand hygiene. For example, we saw staff removing their gloves but not washing their hands after patients contact.
• We found that anaesthetists were not checking equipment on every day of use in line with Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidance.
• We found the medicine cupboard did not lock therefore medicines were not stored securely.
• Staff used the Termination Early Warning Scores (TEWS) to detect deteriorating patients. However this was not yet embedded at the time of inspection. This meant staff may not recognise patient deterioration in a timely manner.
• We saw no identified restraint specific training or any other training that would indicate knowledge or understanding of restraint.
• Due to the close proximity of recovery chairs and open plan layout, patients could overhear conversations with other patients. Staff were therefore unable to protect patients’ dignity and privacy.
• There was a lack of clarity around what constituted a formal and informal complaint. We saw an example of how this had resulted in a complaint still being open after a three month period.
• At the time of inspection the registered manager was in the process of applying to cancel their registration as they no longer had day-to-day responsibility for the MSI Birmingham Centre. Progress on the provider’s action plan to address required improvements identified at our 2016 inspection had been slow, not always effective and lacked oversight.
• Staff did not feel engaged or supported in the change programme.

Heidi Smoult

Deputy Chief Inspector of Hospitals