We observed patients waiting for their appointments and saw they were reassured beforehand by staff in a friendly manner, in appropriate surroundings and a comfortable environment. We saw patients were supported by staff to think through all of the potential options and reach their own decisions about next steps.

We saw that the provider sought people’s view and that patients had said they were satisfied with the standard of care offered at the clinic. They said that clinic had provided good advice and made them feel at ease.

Surgical options are not provided at the clinic but the provider aimed to develop this service. We found that action was taken to assess patients and offer them the appropriate treatment. We saw that staff supported patients to find locations they could easily attend for surgical procedures, as they used medication options at the clinic.

We found that the clinic had policies and procedures in place to ensure patients were treated in a safe environment. We saw that the building was well-maintained.

We found that staff were recruited appropriately and regular checks were completed to make sure their nursing registration remained current. We also found that there were sufficient staff on duty to meet patient’s needs.

We saw there were information leaflets at the reception area and throughout the premises that encouraged patients to make complaints, suggestions or concerns known.

The staff told us when people asked for treatment; they were presented with the options available to them. This was also confirmed by the results of client satisfaction survey where everyone reported being very satisfied or satisfied with the choices of treatment offered. This meant people who used the service understood the care and treatment choices available to them.

People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. Comments from the client satisfaction survey included “Amazing service could not be happier –thank you “and “Staff were lovely.”

Staff were encouraged to develop their knowledge and skills and some had undertaken training to gain additional skills such as counselling. This meant staff received appropriate professional development.

The provider regularly monitored the service to make sure that risks to patient safety were minimised and an appropriate standard of care and treatment was provided.

BPAS Middlesbrough is part of the British Pregnancy Advisory Service. The BPAS Middlesbrough service opened in 2012 and provided termination of pregnancy services, pre and post termination counselling as well as contraception advice and screening for sexually transmitted diseases. At the time of the inspection, the service was providing medical abortions up to 10 weeks gestation to both private and NHS patients. The service provided termination of pregnancy services to children under sixteen and could provide counselling and treatment for patients of any age. The service planned to offer non-scalpel vasectomies in the near future.

We made an announced inspected of the service on 9-10 June 2016 and an unannounced inspection on 17 June 2016 as part of our independent healthcare inspection programme.

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 it provides.

Are services safe at this service?

There was a culture of reporting and learning from incidents across the organisation and within the local services. Staff we spoke with demonstrated an excellent understanding of safeguarding adults and children and knew what actions they needed to take in cases of suspected abuse. All patients received a private initial consultation without anyone else present to safeguard against possible coercion or abuse and to give them the opportunity to disclose such information in a safe environment. All staff had completed training to level 3 in safeguarding for children and adults.

Staffing was sufficient and appropriate to meet the needs of patients in their care. Staff ensured medicines were stored and administered safely. Pathway documents and clinical risk assessments we observed were completed fully and legibly. Staff completed and submitted all Department of Health documentation as required.

Are services effective at this service?

Care was provided in line with national best practice guidelines with the exception of 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. However, patients were given up to date information about the risks and benefits of this treatment before giving consent and the organisation was monitoring outcomes from this treatment.

The complication rate for simultaneous administration at BPAS Middlesbrough was higher than the complication rate across the whole of BPAS. Although higher than that of other centres, the complication rate had not breached the BPAS threshold of 5% and, therefore, had not been viewed as a concern.

We observed that patient assessments were thorough and staff followed pathway guidance. Pain relieving medications were routinely prescribed for patients to take at home following the initiation of treatment.

Observation and assessment of staff competence was an integral part of pathway audit. Staff told us they always made sure patients gave their consent in writing and adhered to Fraser guidelines in respect of children and young people. We observed this in records we saw for patients aged under 18. There were good links with local safeguarding teams and the local NHS hospital.

Are services caring at this service?

Senior managers and staff involved and treated patients with compassion, kindness, dignity, and respect. The results of the BPAS ‘Client Satisfaction’ reports showed 99% of patients at BPAS Middlesbrough would recommend the service to others. Client satisfaction reports showed high levels of patient satisfaction. Client Care Coordinators (CCCs) and nursing staff gave appropriate emotional support to patients. Staff provided all patients with a counselling service before and after termination of pregnancy. There was access to specialist advice and support when needed. We saw examples where staff had gone out of their way to support patients in difficult situations.

Are services responsive at this service?

Service planning monitored activity and staff scheduled sufficient clinics to meet demand. Staff made sure they had enough information and could get further advice when necessary. The service met waiting time guidelines and patients could choose a date or alternative venue for their procedure. The service shared learning from complaints across the organisation, nationally, regionally and locally and staff gave examples of this during the inspection.

Are services well led at this service?

The organisation had a clear mission to provide safe and effective care for termination of pregnancy. Senior managers had a clear vision and strategy for this service and there was good local and regional leadership for the service. Quality of care and patient experience were seen as the responsibility of all staff. There were effective governance systems in place and staff received feedback from governance and quality committees. Staff felt supported by their managers and were confident they could raise concerns and have them dealt with appropriately. There was a corporate risk register in place however a local risk register had not been developed. This was planned to be developed with help from the corporate risk manager. There were some local risks identified and standard operating procedures were in place to ensure business continuity in various situations.

The service was aware of and we observed records and staff working towards Department of Health requirements regarding compliance with the Abortion Act 1967 and the ‘Required Standard Operating Procedures 2014’.

The organisation had a proactive approach to staff and public engagement. Innovation, learning, and development were encouraged.

Our key findings were as follows:

• Staffing levels, medicines’ management and record keeping were good.
• Staff followed policies and procedures.
• Care was provided in line with national best practice guidelines with the exception of 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. However, patients were given up to date information about the risks and benefits of this treatment before giving consent and the organisation was monitoring outcomes from this treatment. The complication rate for simultaneous administration at BPAS Middlesbrough was higher than the amalgamated complication rate for the whole of BPAS. Although higher than that of other centres, the complication rate had not breached the BPAS threshold of 5% and, therefore, had not been viewed as a concern.
• There was enough equipment to allow staff to carry out their duties. The service had processes for checking and maintaining equipment.
• Staff we spoke with understood their responsibilities to raise concerns and report incidents and near misses.
• There was evidence of a culture of learning and service improvement.
• There were systems for the effective management of staff which included an annual appraisal and support for revalidation
• The service had a rolling programme of local clinical audits. Managers monitored and benchmarked performance of all units across the organisation using a performance dashboard.
• Leaders were aware of their responsibilities to promote patient and staff safety and wellbeing.
• Leaders were supportive and the culture encouraged candour, openness, and honesty.

We saw several areas of good practice including:

• Staff went out of their way to provide a caring and holistic service to their patients. They did this by working well with local agencies and charities to provide additional support and services for vulnerable patients.
• Regular, direct observation of staff practice was an integral part of the BPAS approach to ensuring staff maintained an expert level of competence in their individual roles.
• All members of the team worked together to ensure they gave patients the best possible experience of the treatments given and the service offered.
• The provider ensured that all patients received a private initial consultation without anyone else present to protect patients against possible coercion or abuse and to give them the opportunity to disclose such information in a safe environment.
• Staff had access to a specialist placement team who would arrange referral to appropriate providers for patients with complex or additional medical needs, who did not meet usual acceptance criteria.
• Staff knew their own role and remit for safeguarding children and vulnerable adults, and had a heightened awareness of the needs and vulnerabilities of children and young people using their service.
• Completion of records complied with prescribed practice and was consistently of a high standard.

Professor Sir Mike Richards

​Chief Inspector of Hospitals