BPAS - London East

BPAS London East is part of the provider group British Pregnancy Advisory Service (BPAS). It provides a range of termination of pregnancy services for early medical abortion (EMA) up to a gestation of 10 weeks, surgical termination of pregnancy using vacuum aspiration with local anaesthetic up to a gestation of 12 weeks and surgical termination of pregnancy with conscious sedation up to a gestation of 13 weeks 6 days.  The service also provides pregnancy testing, unplanned pregnancy counselling/consultation, abortion aftercare, sexually transmitted infection testing, vasectomy, and contraceptive advice and contraception supply.

We carried out this announced comprehensive inspection on 2 and 3 June 2016 and a follow up unannounced inspection on 10 June 2016. We inspected this service as part of our independent healthcare inspection programme.

We have not provided ratings for this service because we do not currently have a legal duty to rate this type of service or the regulated activities which it provides. Our key findings were as follows:

Is the service safe?

• Between January and December 2015 the service reported compliance rates with the World Health Organization (WHO) Surgical Safety Checklist ranging from 89% to 100% for surgical termination of pregnancy and vasectomy. Areas for improvement included ensuring the pre-operative checks were fully documented. However, we found there was no pre-operative briefing and no de-briefing after surgery. Both of these elements contribute to the five steps.

• There were ineffective processes for the proper and safe management of medicines. We found discrepancies in the stock of abortifacient medicines which senior managers could not account for. This was investigated by the provider after our inspection and remedial action taken.

• Some medicines were stored in three unlocked cupboards in the recovery area, including a cupboard under the sink. We brought this to the immediate attention of the registered manager and saw that medicines were transferred to a locked cupboard. On our unannounced inspection all medicines were stored correctly.

• National specifications for infection prevention and control were not always adhered to. Cleaning instructions and monitoring of cleaning standards were not in place. There was a lack of segregation of clean and dirty surgical equipment in the dirty utility room and no cleaning checklist in the treatment room.

• Calibration checks were not carried out on some equipment on a regular planned basis, including equipment used for the diagnosis and management of patient treatment and care.

• The standard BPAS incident reporting process and documentation was in place. The incident form booklets were located in the registered manager’s office in the clinical administration area. All incidents were escalated to BPAS head office by the clinic registered manager, which was current BPAS policy. This meant that staff were unable to report concerns independently and staff and managers acknowledged this could lead to under reporting.

• Staff demonstrated their understanding of safeguarding adults and children. They described actions to take in cases of suspected abuse, knew how to access policies and had completed recent safeguarding training to an appropriate level.
• Patient records were stored securely, were legible and were mainly completed in accordance with prescribed practice.
• All the patients undergoing abortion underwent a risk assessment to determine their individual risk of developing blood clots.
• There were sufficient numbers of suitably trained staff available to meet patients’ needs.
• Arrangements and instructions were in place to manage emergencies and transfer patients to another health care provider where needed and were known by staff.

Is the service effective?

• Staff had access to relevant guidelines, policies and procedures. Care was provided in line with Department of Health Required Standard Operating Procedures (RSOPs) and national best practice guidance such as NICE and Royal Colleges and professional regulatory standards such as those produced by GMC and NMC. The service had completed a programme of clinical audits depending on risk assessments.
• The exception was the use of simultaneous administration of abortifacient drugs for early medical abortion (EMA), which is outside of current Royal College of Obstetrician and Gynaecologist (RCOG) guidance. We saw that a structured governance system was in place and had been followed to introduce this treatment option.
• There were systems for the effective management and development of staff which included an annual appraisal.
• Patients were offered pain relief, prophylactic antibiotic treatments and post-abortion contraceptives.
• Staff providing counselling participated in group counselling supervision in line with best practice guidance.

Is the service caring?

• We observed that staff were caring and compassionate and treated patients with dignity and respect. Feedback from patients highlighted that their wishes were respected and their beliefs and needs were taken into account.
• We saw during the initial assessment, nurses and midwives explained to patients all the available methods for termination of pregnancy that were appropriate and safe and this was recorded in patients’ notes. Staff considered gestational age and other clinical needs whilst discussing these options.
• Patients considering termination of pregnancy or vasectomy had access to pre and post counselling, with no time limits attached, but were not obliged to use the counselling service.
• We could not observe how staff treated male patients because there were no vasectomy clinics in progress during our inspection. However, we spoke with staff, considered patient feedback and information, and reviewed five records for patients who had undergone vasectomy procedures. Vasectomy patients gave positive feedback in the BPAS patient satisfaction reports submitted between September and December 2015.

Is the service responsive?

• Patients either referred themselves or were referred by their GP. They were able to book appointments through the BPAS telephone booking service which was open 24 hours a day throughout the year. This also enabled patients to choose the location they attended.
• There was no formal monitoring of waiting times or the reasons for any delays. However, staff told us they could not recall any significant delays.
• Patients were referred to other services for termination of pregnancy, where appropriate, for example due to a medical condition or late gestational age. Patients could attend other local BPAS clinics for treatment if BPAS London East was closed.
• Patients were provided with information to help them to make decisions.
• The service had systems in place to ensure pregnancy remains were disposed of according to national guidance.
• A professional interpreter service was available for patients whose first language was not English, to enable them to communicate with staff. We saw this used effectively and in a timely manner.
• Complaints were managed locally and, where unresolved, were escalated to the central office to be managed by the complaints manager and client engagement manager. Feedback was given to staff and the complainant. The clinic identified trends in complaints, which included delays in clinic start times.

Is the service well led?

• There were corporate governance arrangements to manage risk and monitor quality. This included an audit programme and an established system to cascade learning. However, the arrangements for governance mainly took place at national and regional levels and did not always operate effectively locally. Risks were not always identified or acted upon at the clinic by people with the authority to do so. In particular, monitoring and review of medicines management and infection prevention and control were not effectively managed.
• Legislation requires that for an abortion to be legal, two doctors must each independently reach an opinion in good faith as to whether one or more of the legal grounds for a termination is met. They must be in agreement that at least one and the same ground is met for the termination to be lawful, and sign a form to indicate their agreement (HSA1 Form). All of the records we looked at met these requirements.
• The culture within the service was caring, non-judgmental and supportive to patients. Staff spoke positively about the need for and value of the service to patients.
• Service development was encouraged: for example the introduction of surgical termination under conscious sedation in May 2016.
• Staff felt supported by their registered manager and regional operations director.

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

Importantly the provider must ensure:

• A formal review of the pharmacy service and a consistent approach to medicines management audit to ensure delivery, stock control and storage of medicines is managed in accordance with legislation, provider policy, and professional standards and national guidance.
• A list of authorised signatories is kept at the clinic to identify named practitioners who order, receive and administer medicines.
• Ensure briefings and de-briefings are fully implemented and documented in accordance with the World Health Organization (WHO) Surgical Safety Checklist.
• National specifications for infection prevention and control and cleanliness are adhered to including: segregation of clean and dirty equipment and waste in all clinical areas, and staff comply with national dress code standards for infection prevention and control.
• All areas in which patients are treated are clean and cleaning schedules and checklists are maintained in sufficient detail to demonstrate this.
• Safety checks including calibration are carried out on all equipment including that used for clinical diagnosis on a regular planned basis.

The provider should ensure:

• All staff at the clinic are actively involved in assessing local risks, local audit and clinical review. This should be proportionate and relevant to their role. Staff should be given training and support to take responsibility for maintaining standards.
• Staff are supported to independently report incidents of all kinds, including those with a potential to cause harm to patients or staff, even when no harm occurred. All staff should receive prompt feedback to reduce the risk of recurrence of incidents.
• Ensure documentary evidence that demonstrates men undergoing vasectomy have their pain assessed using a recognised pain score and that pain is treated.

Professor Sir Mike Richards

Chief Inspector of Hospitals