BPAS - Doncaster

Updated 16 June 2022

The British Pregnancy Advisory Service was established as a registered charity in 1968 to provide a safe, legal abortion service following the 1967 Abortion Act. BPAS Doncaster opened in 1982 and provided a satellite site in York.

BPAS Doncaster provides medical and surgical termination of pregnancy services, feticide treatment, screening for sexually transmitted diseases, contraception advice, counselling, contraception, and vasectomy procedures. Facilities included three screening rooms, seven consultation rooms, and a treatment room. Following the last inspection, the service had suspended late medical terminations of pregnancy and closed eight inpatient beds for overnight stays for patients undergoing these treatments.

The BPAS Doncaster clinic carries out; early medical and surgical abortion under local anaesthetic, with or without conscious sedation, and under general anaesthetic.

The location is registered to provide the following regulated activities:

• Termination of pregnancies

• Surgical procedures

• Treatment of disease, disorder or injury

• Family planning

• Diagnostic and screening procedures

The location has a manager registered with CQC.

BPAS Doncaster was last inspected 4 August 2021 following information highlighted at routine engagement on 15 June 2021. Following the last inspection, CQC took enforcement action which included the use of our urgent enforcement powers, conditions were placed on the location’s registration in relation to safe care and treatment, consent and safeguarding. This inspection found significant improvements to policy and practice in these areas.

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 question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Updated 16 June 2022

Our rating of this location improved. We rated it as requires improvement because:

• The service had suitable premises and equipment. There were enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The service provided mandatory training in key skills to all staff and made sure everyone completed it. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• Staff kept detailed records of patients’ care and treatment and followed BPAS processes when prescribing, administering, recording and storing medicines. Staff completed and updated risk assessments for patients undergoing surgical and late medical terminations of pregnancy. The service reported and managed patient safety incidents well.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Staff assessed and monitored patients regularly to see if they were in pain. Staff followed appropriate consent processes. Staff supported patients to make informed decisions about their care and treatment. Staff promoted sexual health in line with national guidance. There was an emergency transfer agreement with the nearest acute hospital.
• Staff cared for patients with compassion and provided emotional support to patients. Staff involved patients’ decisions about their care and treatment.
• The service managed and investigated concerns and complaints appropriately. The service coordinated care with other services and providers.
• The service had a vision for what it wanted to achieve and workable plans to turn it into action. Managers promoted a positive culture that supported and valued staff. There was inclusive and effective leadership at all levels. Leaders demonstrated the experience, capacity and capability needed to deliver sustainable care.
• Staff throughout the service were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities, were proud of the organisation as a place to work and spoke highly of the culture. Staff were actively encouraged to speak up and raise concerns.

However, we found the following areas where the service could improve:

• Staff could not articulate how to assess risk of deterioration in children and there were no supplies of emergency equipment suitable for intubation of children.
• There was no thermometer to monitor the temperature of the nurses’ office where the to take out (TTO) medicine cupboard was located. This could impact on the stability of the medicines stored within this area.
• People could not access the service when they needed it to receive the right care promptly. Although waiting times had improved, these were not in line with national standards.
• Although leaders had begun to operate effective governance processes throughout the service and used systems to manage performance effectively, these were new processes and had not had time to become embedded in practice or show consistent improvements.

Updated 16 June 2022

We rated this service as requires improvement because it was effective and caring although safe, responsive, and leadership requires improvement.

See summary for more information.

In the reporting period 1 September 2021 to 31 March 2022., the centre carried out 638 surgical terminations of pregnancy (SToP) under local anaesthetic/conscious sedation and under general anaesthetic, 7294 early medical abortions including oral medicines by collection and by post, and no late medical terminations of pregnancy. The service also carried out 196 vasectomy consultations and 172 non scalpel vasectomies. The centre held a current Department of Health licence to practice under the Abortion Act and displayed copies of the licence at each of its registered locations

Two surgeons were directly employed by BPAS.

Track record on safety:

• No never events and one serious incident requiring investigation reported from September 2021 to March 2022.
• Four patients were transferred out to another hospital from September 2021 to March 2022.
• No incidences of hospital acquired Methicillin-resistant Staphylococcus aureus (MRSA)
• Two complaints were received within the reporting period from September 2021 to March 2022.