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BPAS - Peterborough, North Wing, Broadway Court, Peterborough.

BPAS - Peterborough in North Wing, Broadway Court, Peterborough is a Clinic specialising in the provision of services relating to diagnostic and screening procedures, family planning services, services for everyone, surgical procedures, termination of pregnancies and treatment of disease, disorder or injury. The last inspection date here was 5th September 2019

BPAS - Peterborough is managed by British Pregnancy Advisory Service who are also responsible for 35 other locations

Contact Details:

    Address:
      BPAS - Peterborough
      Ground Floor
      North Wing
      Broadway Court
      Peterborough
      PE1 1RS
      United Kingdom
    Telephone:
      03457304030
    Website:

Ratings:

For a guide to the ratings, click here.

Safe: No Rating / Under Appeal / Rating Suspended
Effective: No Rating / Under Appeal / Rating Suspended
Caring: No Rating / Under Appeal / Rating Suspended
Responsive: No Rating / Under Appeal / Rating Suspended
Well-Led: No Rating / Under Appeal / Rating Suspended
Overall: No Rating / Under Appeal / Rating Suspended

Further Details:

Important Dates:

    Last Inspection 2019-09-05
    Last Published 2017-01-13

Local Authority:

    Peterborough

Link to this page:

    HTML   BBCode

Inspection Reports:

Click the title bar on any of the report introductions below to read the full entry. If there is a PDF icon, click it to download the full report.

17th May 2016 - During a routine inspection pdf icon

The Care Quality Commission (CQC) carried out an announced comprehensive inspection at British Pregnancy Advisory Service (BPAS) Peterborough on 17 May 2016. This service was inspected as part of a wider programme to inspect providers of acute independent healthcare.

BPAS Peterborough provides consultations, ultrasound scans, medical and surgical termination of pregnancy, and counselling and support for people who use the service. In addition, long acting reversible contraception and sexually transmitted infection testing and screening are offered. BPAS Peterborough also provides services via one treatment unit (BPAS Cambridge).

BPAS Peterborough provides consultation, early medical abortion (EMA) and medical abortion treatments up to 10 weeks gestation and surgical treatment up to 13 weeks gestation. Surgical termination is carried out under local anaesthetic by vacuum aspiration.

Our key findings across all the areas we inspected were as follows:

Are services safe at this hospital?

Staff we spoke with were confident to report serious incidents, whistleblow or challenge if they suspected poor practice. Incidents, near misses and serious incidents were standard agenda items at BPAS Regional Quality, Assessment and Improvement Forums (RQuAIF).

Staff adhered to “bare below the elbows” and were observed to undertake appropriate hand decontamination to reduce the risk of infection. Recommendations identified in recent infection prevention and control (IPC) audits (BPAS hazardous waste inspection and the May IPC audit) had been actioned.

All the equipment reviewed during the inspection had been serviced by an appropriate contracted company and maintenance dates were visible on the equipment.

There were systems in place for medicine management that included obtaining, recording, handling, storing and security of medicines.

All eight staff had undertaken BPAS training for safeguarding vulnerable groups - level three. Staff were knowledgeable about safeguarding concerns and documented evidence demonstrated that safeguarding assessments had been completed and appropriate safeguarding referrals had been made for patients under the age of 16.

Evidence of risk management and accountability for the treatment unit in Cambridge was not provided. Specifically in relation to checking of the emergency equipment, ensuring a risk assessment or service level agreement was in place for appropriate care of a deteriorating patient and consideration of a risk assessment in relation to lone working safety requirements. Staff at a local level had not received any training on dealing with violence and aggression.

Not all references to national guidance and standards listed in the Medicines Management Policy 2015 were the most up to date version, despite a recent review. Subsequent data provided following the inspection stated that the Medicines Management Policy 2015 policy had been under review by the clinical governance committee (CGC) at the time of inspection. However no material changes were made to the reference documents or the BPAS policy as a result of this review.

Are services effective at this hospital?

Policies were accessible for staff and there was a system in place for auditing and review via regional and provider level clinical governance. There was a system for patient clinical outcomes to be reviewed at regional and provider level. Staff we spoke with stated that outcomes were discussed at local team meetings. However, this was not minuted.

All staff were appropriately qualified and had received training in accordance with their role. One-hundred per cent of registered nurses had undergone an annual appraisal and 80% of administration staff.

Training data provided demonstrated that both registered nurses and the registered midwife at BPAS Peterborough had received consent workshop training in line with the provider policy.

Are services caring at this hospital?

Staff offered a good service to patients and were helpful, caring and treated patients with dignity and respect. We observed that staff adopted a non-directive, non-judgemental and supportive approach to patients seeking and receiving treatment for termination of pregnancy.

Views from patients were positive and described staff as caring. Results from the patient survey, December 2015, were 100% for confidence and trust in staff and patients treated with dignity and respect.

Staff were clear on the range of emotional responses that women and those close to them may experience during and following a termination.

Staff were recruited in accordance with the BPAS Recruitment and Selection Policy and Procedure, which explored whether candidates were pro-choice. BPAS did not employ or subcontract individuals with a conscientious objection to abortion, or those who did not embrace the organisational beliefs.

Are services responsive at this hospital?

Services were planned and delivered in a way that met the needs of the population and reflected the importance of flexibility and choice for patients. Commissioners and stakeholders were involved in service planning.

Data provided between January and December 2015 demonstrated that 77%of patients received treatment below 10 weeks gestation at BPAS Peterborough, which was above the national average.

Data provided demonstrated that BPAS Peterborough was achieving the target that patients are offered an appointment within five working days of referral or self-referral, as per RSOP 11, in the majority of cases. Achieving between 81% and 91% in each quarter of 2015/16. The percentage of patients receiving a termination procedure within five working days of the decision to proceed was between 73% and 85% in each quarter of 2015/16.

Midwives and nurses undertaking assessments had a range of information that they could give to patients as required. Translation services were available for patients who did not have English as a first language.

There was a complaints procedure in place, and posters displayed in the clinic to inform and encourage people to raise concerns where necessary. There had been no complaints reported between January and December 2015.

We were informed that there were plans to improve capacity and flow. A business case was being developed to increase the number of days the Peterborough centre was open and increase the number of surgery days per month with the aim to reduce waiting times.

Are services well-led at this hospital?

Governance took place at regional and national levels however data provided did not demonstrate this at a local level.

Risk processes were not effective at location level. The centre manager was not trained in risk management and there was a lack of risk assessments to show a proactive approach to risk management at location level.

There was no risk register to enable risks to be identified, managed and reduced in a timely manner.

There was a lack of ownership or responsibility for processes and risk management at the Cambridge treatment unit.

Staff we spoke with stated that team meetings were utilised to discuss incidents, outcomes, complaints and ensure learning. However, team meetings were not minuted, so there was no official record of agenda items discussed or actioned at the meetings.

However, staff were aware of the vision and strategy at BPAS Peterborough, which was to deliver high quality care, promote good outcomes for patients and encompass key elements such as involvement, kindness, a non-judgemental approach and choice for patients. The culture was viewed as supportive and corporately led.

Processes were in place to make sure that the certificate(s) of opinion HSA1 were signed by two medical practitioners in line with the requirements of the Abortion Act 1967 and Abortion Regulations 1991 and the subsequent arrangements for submission of HSA4 forms.

Patient and staff engagement was good, with positive comments of a friendly environment where patients and staff were valued and respected.

We saw the following area of good practice:

  • Staff were described and observed as being non-judgemental.

However, there were areas of poor practice where the provider needs to make improvements.

Importantly, the provider should:

  • Ensure that senior staff at a local level receive training and development with regard to risk management.
  • Ensure clear guidelines are provided to evidence who is accountable for managing and checking emergency equipment at the treatment unit.
  • Review local risk management practices, such as local risk registers and risk assessments for the treatment unit staff regarding safety, management of deteriorating patient, equipment and environment.
  • Ensure that staff at a local level have access to violence and aggression training.
  • Ensure team meetings are minuted to demonstrate good communication and engagement of all staff at all times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

23rd January 2014 - During a routine inspection pdf icon

We spoke with three people who were using the service. They were well informed about the treatment options and felt supported to make decisions. They told us they had discussed consent with the nurses in the clinic who had made it clear they could change their decision following their initial consultation in the run up to treatment or on the day of treatment.

We reviewed four sets of records and saw they contained information about the length of the pregnancy, the person’s medical history, treatment provided and plans for discharge and follow up. We saw copies of the legally required certificates signed by two authorising doctors.

There was an infection control plan in place which described the provider's plan for complying with the required standards. This included risk assessments for people using the service and the clinical environment.

We looked at staff records and found they all contained the required recruitment documentation. The provider had arrangements in place to ensure people received treatment from suitably qualified staff.

22nd March 2012 - During a themed inspection looking at Termination of Pregnancy Services pdf icon

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.

29th November 2011 - During a routine inspection pdf icon

People who we spoke with said that they were satisfied with the information that they had received, including information before and after their treatment.

One person told us that the staff were, "Very helpful. They made me feel comfortable, when I was being treated and they told me what I should expect to happen".

1st January 1970 - During a routine inspection pdf icon

People we spoke with confirmed that their consent was obtained before any procedure was started. They were provided with enough information in a format suitable for them and they were able to change their mind about treatment options.

Care records were clear and were written in enough detail to provide guidance to staff members and an audit trail of the care provided to women. Women we spoke with said staff supported them during their treatment and with their care needs.

Medicines were stored appropriately and accurate records were kept to show those administered during each woman’s treatment at the service.

Recruitment checks were not all carried out or obtained prior to new staff members starting work with the service. This was partly rectified during our visit, although this did not ensure staff members were safe to work.

There were systems in place to regularly check and monitor the way the service was run. Every woman using the service was given the opportunity to comment about their experience and the service they had been given.

 

 

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