Overall, we found this was not a well-led service and improvements were needed to ensure a safe, effective, and response service. However, staff provided a good standard of care. This was because:

• The staff we spoke with understood how to report adverse incidents, errors, or near misses. They were aware that such matters would be investigated. However, actions required of staff to minimise risks to patients were not always addressed promptly.

• Patients were not always informed where an incident occurred, which may have affected them. They did not always receive information about this or the outcome, including any actions taken. The reporting of serious incidents was not always made to the CQC.

• The duty of candour regulation was not embedded in the culture of the service. Staff were not sufficiently aware of the regulatory requirements, especially providing a written apology.

• Learning from the investigation of adverse events, near misses and complaints was not evident. Staff could not provide any significant examples of such learning or changes in practices.

• Staff did not undertake a pre-surgical brief or de-briefing following surgery. These practices are recommended as part of the World Health Organisation (WHO) ‘five steps to safer surgery’.

• Infection prevention control (IPC) procedures did not adhere to The Health and Social Care Act 2008, Code of Practice on the prevention and control of infections and related guidance or associated national guidelines. Systems to manage and monitor the prevention and control of infection were not fully implemented and acted upon. These systems use risk assessments and consider the susceptibility of service users and any risks that their environment and other users may pose to them. Further, systems to ensure that all care workers (including contractors and volunteers) are aware of and discharge their responsibilities in the process of preventing and controlling infection were not sufficiently robust. Staff did not follow correct IPC practices in the operating theatre with regard to dress code and use of personal protective equipment.

• Policies were accessible to staff but these did not always reflect the most recent professional guidance.

• Safeguarding policies were not up to date and did not include the latest requirements, and published guidance. This included the new Care and Support Guidance published in March 2016, chapter 14 of which replaces the ‘No secrets’ guidance. Additional guidance within the aforementioned document includes for example, coercion in domestic abuse, safeguarding adults training, and the Modern Slavery Act 2015.

• Although staff had completed the corporate mandatory required safeguarding training, they had not completed level three safeguarding training, in regard to statutory guidance; ‘Working Together to Safeguard Children. (2015). This references the intercollegiate document 2014, Safeguarding Children and Young People: Roles and Competences for Health Care Staff. Level 3 training is required of clinical staff working with children, young people and/or their parents/carers and who could potentially contribute to assessing, planning, intervening and evaluating the needs of a child or young person and parenting capacity where there are safeguarding/child protection concerns.

• Throughout the patient’s pathway of care, they were not given information for the disposal of human remains, in line with the Human Tissue Authority guidelines March 2015. There was no evidence that discussions took place and staff told us they did not provide this option for patients, unless they raised the matter.

• There was no local pharmacist input into monitoring medicines optimisation or audit processes. Expired and unused medicines were not disposed of correctly, and there was no auditing check compliance with the required practice. Medicine top up arrangements at satellite locations did not follow the corporate medicines management policy in full.

• Staff were given induction training and additional training to specialise in areas of treatment, such as undertaking scans and providing contraception. However, staff did not receive training in the Mental Capacity Act (2005), and as a result had limited knowledge with regard to this matter.

• Required Operating Standards (RSOP)14 and Royal College of Obstreticians and Gynaecologists guidelines related to consent were not sufficient. Adult and child consent for treatment had been devolved to nurses and healthcare assistants. Questions raised by patients during the consent process could not always be answered due to a lack of knowledge, which indicated training had not been sufficiently detailed. Further, this devolved responsibility meant the medical practitioners were not following the General medical Council (GMC) guidance with respect to deciding whether a young person was able to understand the nature, purpose and possible consequences of investigations or proposed treatments, as well as the consequences of not having treatment.

• With the exception of anaesthetic risk assessments, patients received nursing assessment of risks prior to procedures and following treatment.

• There was a corporate vision and strategy; however, staff were not fully aware of what this was and the part their role-played in the company’s success.

• There was a lack of oversight of local professional practices, staffs adherence with professional guidance and monitoring of standards. Further, the location manager was not empowered to make decisions on behalf of the centre. Therefore, it was difficult for staff to be innovative and inspired.

• Lone workers at satellite sites often felt vulnerable when dealing with difficult situations. Staff were able to tell us of incidents where their safety was compromised.

• Appointments times were sometimes booked for several people. Waiting rooms were not always large enough to accommodate all attendees, and there were lengthy waits for planned appointments.

However positive findings included:

• Sufficient staff were available to support patients using the service. There was minimal use of bank and agency staff. Staff were able to work at different locations when demand was high, which allowed flexibility for staffing cover.

• An early warning score system was used to assess patients. Procedures were set up to transfer women to a local NHS hospital, should they deteriorate.

• Other Required Operating Standardswere generally followed by the staff, although such standards were not explicitly stated in the information we reviewed. Accessibility, gestational limits and treatment options, patient confidentiality, maintenance of equipment, counselling, and information provision broadly met the RSOP. The service also participated in regular monitoring to monitor patient outcomes such as individuals who did not proceed with treatment, failed abortion rates, and infections.

• Staff showed compassionate and kind care and treated clients with dignity and respect. Patients told us staff were understanding and non-judgemental.

• Staff generally respected the privacy of patients during their treatment and gave them time to make informed decisions. Patients were not pressurised and were given time to consider before consent was taken.

• Staff were mostly knowledgeable about medical and surgical treatment options, and were able to provide patients with the appropriate information. They had a comprehensive understanding of contraception and were able to offer choices and support patients with their decisions.

• Staff monitored individuals for pain and offered the appropriate pain relief when required. Staff would seek the advice of senior staff if they felt patients were becoming distressed.

• Staff told us they enjoyed working for Marie Stopes International. They liked working in different locations and felt they had the chance to develop their skills.

• The centre operated a six-day week service. Patients were offered a selection of appointment times to suit their needs. Flexible, alternative arrangements at other centres were available to accommodate their requirements. There were good arrangements in place for out of hour’s access, with a 24-hour contact line available for individuals to use.

• A selection of information was available to patients, in the form of leaflets, booklets, the company’s website, and face-to-face discussions with staff. Such advice included abortion treatment, the different types of contraception available, and support groups.

• People who used the service had the opportunity to provide feedback and offer suggestions for improvement.

During our inspection visit to Marie Stopes International services we used a variety of methods to inspect the service. Including observation skills to find out how peoples needs were being met. We spoke with two people using the service, three members of staff and reviewed the documented evidence provided.

The two people using the service spoke highly of staff and felt well cared for during their time at the clinic. They felt involved in their care and treatment and reassured by access to the 24 hour helpline.

During our inspection we found some concern when talking to staff specifically relating to them having to work on a regular basis beyond their contractual hours. Although improvements in staffing and ways of working had been acknowledged we observed that during our visit staff were having to work beyond their finishing time to meet the needs of the people using the service on that day. One staff member who should have finished at 4pm was still there at 6pm we observed that the last person using the service was there until 7pm.

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.

People find that the centre offers a friendly welcoming environment and that individuals are progressed through the care and treatment pathway without unnecessary delays. They receive prompt consultations on whatever the service required both via the call centre and on visiting the centre.

People requiring treatment that includes a termination of pregnancy receive confidential professional advice and support so hat they can make an informed decision.

People find the service accommodating and have appointments offered at convenient times. People have private consultations with trained staff on contraception, and can have screening for sexually transmitted disease.

People find that they are fully assessed with scans and blood testing undertaken prior to surgical or medical terminations. Aftercare following surgical procedures for individuals is good; people are monitored closely by trained nursing staff before discharge arrangements are made.

Marie Stopes UK International (MSI) is operated by MSI International and is a not for profit organisation. The facilities at MSI south London include a treatment room with diagnostic services and a ward area with 10 day couches (eight in the main ward area and two in a private room). There are also four consultation rooms and a discharge room.

MSI south London provides consultations, medical and surgical termination of pregnancy services, vasectomy procedures, ultrasound scanning, screening for sexually transmitted diseases, long acting reversible contraception and counselling for people who use these services.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 26 July 2017, along with an unannounced visit to the centre on 3 August 2107. We inspected the early medical abortion unit (EMU) at Wimbledon on 1 August 2017.

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.

CQC undertook enforcement action, following an inspection of the governance systems at the MSI corporate (provider) level in late July and August 2016. There were several breaches in regulation identified at corporate level that were relevant to MSI south London.

The breaches were in respect of:

Regulation 12 Care and treatment must be provided in a safe way for service users.

Regulation 20 (Registration) A healthcare service body must act in an open and transparent way with relevant persons in relation to care and treatment provided to service users carrying on a regulated activity.

We followed up these concerns as part of this inspection.

Services we do not rate

We regulate termination of pregnancy services but we do not currently have a legal duty to rate them when they are provided as a single specialty service. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the following areas of good practice:

• Nursing staff had received additional anaesthetic and recovery training to support the anaesthetist during patient care.
• Nursing staff received support and training from the clinical operations manager and clinical team leader. Additional training had been provided, such as duty of candour and haemorrhage control training.
• Staff respected patient’s wishes and provided dignified and supportive care.
• New systems were in place to check infection prevention and control and cleaning practices.
• Policies had been reviewed and updated to follow national guidelines. These were readily available to all staff.
• All staff at the centre were up to date with their safeguarding vulnerable children, young people, and adults training.
• Equipment servicing records were organised and well maintained.
• Patient records and risk assessments scores were detailed and legible.
• Systems were in place to escalate and transfer deteriorating patients to an NHS hospital if required.
• Translation services were available for those patients where English was not their first language.

However, we also found the following issues, which the service provider needs to improve:

• Patients faced frequent delays with their appointments and treatment due to the heavy caseload at the centre and lack of consultation time. This meant delays to the clinical lists, which then led to cancellations.
• The registered manager had not received root cause analysis (RCA) training to help investigate serious incidents.
• The waiting area was not able to accommodate all the patients on busy days. Staff told us patients often sat on the floor in the waiting area.
• Lessons learned from incidents were not consistently shared with staff.
• The revised audit programme had been introduced but was not fully embedded at the centre. There were no recommendations made from poor outcomes of these audits to help improve standards.

Following this inspection, we told the provider that it should make other improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Amanda Stanford

Interim Deputy Chief Inspector of Hospitals