Patient's being supported by the service told us they were satisfied with the standard of care and support provided by the staff team. They made various positive comments such as:

"Everything has been explained to us at every step" and "We have no complaints, the staff have been there throughout the visit answering all our questions."

Various quality assurance checks on the service helped to show systems were in place to ensure that the service was effectively managed and had evidence of being compliant and promoted good practices. Appropriate systems were in place in regard the event and management of emergency procedures and auditing of the standard of record keeping within the service.

Staff were positive about working for the service and felt they were well supported with their training needs to be able to meet patient's individual needs.

We spoke with two people who had used the service. People said they had been happy with the care and treatment they had received at the clinic. They told us that all options had been discussed with them before they decided which treatment to undergo. They said they had been treated with respect and their privacy had been maintained at all times. People had been offered appointments promptly and to suit their needs. People's needs were assessed and they agreed a pathway of care which ensured their needs were met safely.

Staff were described as being polite, friendly, non judgemental and caring. People told us they felt safe at the clinic and staff were good at their jobs.

There were high standards of cleanliness and infection control at the clinic and medical and non medical equipment had been regularly checked to ensure it was safe to use.

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.

• There was no robust system in place to ensure that resuscitation equipment was regularly checked to keep patients safe. It was not clear whether several pieces of equipment used in theatre had been subject to the appropriate maintenance tests.

• The service had reported 11 serious injury notifications to the CQC from January 2013 to March 2016 (eight of which were reported between January 2015 and March 2016). All of these incidents resulted in patients being transferred to the local NHS trust for emergency care. Investigation reports completed following each serious incident did not identify and consider all relevant information and contributory factors

• Infection control procedures were not always followed in theatre and we were not assured that medication was regularly reviewed and replaced as required.

• Whilst most services offered by the provider were in line with current RCOG guidance, the practice of simultaneous administration was not in line with current RCOG guidance. BPAS currently offered treatment for early medical abortions either by way of the simultaneous administration of the medicines necessary to effect a termination of pregnancy (only for pregnancy under 9 weeks) or initial dose followed at some point within a 72 hour window with a second medication. The provider no longer offers an interval of 6-8 hours between administrations of the medications because the outcomes with this interval were not found to be significantly better than with simultaneous administration.

• The service had agreed standards in place with commissioners. Whilst quarterly monitoring reports to the commissioners gave details of service delivery, they did not include details of agreed targets so it was not clear how well the service was performing. It was also not clear how this information was used to improve service delivery or patient outcomes.

• Patients were not informed about the statutory requirement of HSA4 forms. Staff did not explain to patients that these details were sent to the Department of Health and that it was a legal requirement.

• A quarterly monitoring report to one of the commissioners showed patients were not always seen within RCOG recommended timeframes. The reasons for delays or extended waiting times were not given in the report but it was possible that these delays were due to patient choice.

• Local governance arrangements did not ensure the identification, mitigation and monitoring of risks or the improvement of quality and patient outcomes. We were not assured that the registered manager had full understanding and grip of the potential risks within the service and the supporting clinical governance arrangements. When asked to supply the full root cause analysis investigation reports following the recent serious incidents, the registered manager was not clear on who had completed the investigation reports, had not been involved in the production of the investigation reports and had not had sight of the full investigation reports. She was unaware that staff did not have sight into the outcomes of the serious incident reviews.

• There was no local risk register or other document that identified local risks and the control measures in place.

• Information from corporate and regional governance meetings should have been shared with staff via staff meetings and nurses meetings. However, we did not see minutes from any staff meetings where this information was shared despite requesting them. Bank and agency staff were not informed of any changes and were not invited to any BPAS staff meetings.

However:

• The service had clear systems in place to identify and report safeguarding concerns. Staff we spoke with were aware of the safeguarding policy and who to report their concerns to.

• The clinic followed the BPAS planned programme of audit and monitoring. Audit outcomes and service reviews were reported to the governance committees and Regional Quality, Assessment and Improvement Forums (RQuAIF).

• Appropriate systems were in place to obtain consent from patients and consent was well documented in the patient record.

• BPAS had various competency frameworks in order to support the training and development of staff. All medical staff and 89% of registered nurses had undergone an annual appraisal in the last full year (January to December 2015).

• We observed staff using a caring and compassionate approach particularly in the recovery room where patients were transferred after surgery. Patient feedback forms indicated the majority of patients felt listened to and felt that their confidentiality was maintained. They also indicated the majority of patients would recommend the service.

• The service was planned and delivered to meet the needs of patients. Following work in partnership with Antenatal Results and Choices (ARC) the decision had been made to provide terminations of pregnancy for foetal anomalies.

• There was a corporate governance committee structure in place to capture and discuss identified risks. The framework also enabled the dissemination of learning and service improvements and a pathway for reporting and escalation to the BPAS board.

• The provider had recognised that local governance processes needed strengthening and had recently employed a risk management and client safety lead who was responsible for reviewing systems and was working with registered managers to implement systems such as a local risk register and improved incident reporting systems.

• Practising privileges were reviewed annually by the medical director and registered manager. The clinical department at Head Office flagged when an individual’s practising privileges were due. Clinicians had a month to submit the necessary documentation otherwise their practise was suspended until the information was provided.