The Care Quality Commission
  • Hospital
  • Independent hospital

BPAS - Birmingham Central

Overall: Good read more about inspection ratings

1st Floor, Guildhall Buildings, 12 Navigation Street, Birmingham, West Midlands, B2 4BT 0345 730 4030

Provided and run by:
British Pregnancy Advisory Service

All Inspections

21 July 2022

During a routine inspection

Our rating of this location stayed the same. We rated it as good because:

  • The service had enough staff to care for clients and keep them safe. Staff had training in key skills, understood how to protect clients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to clients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
  • Staff provided good care and treatment and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of clients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated clients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to clients, families and carers.
  • The service planned care to meet the needs of local people, took account of clients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of clients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with clients and the community to plan and manage services and all staff were committed to improving services continually.

14th May 2019

During a routine inspection

BPAS Central is operated by British Pregnancy Advisory Service (BPAS). It comprises one main location in central Birmingham and one satellite location in Dudley.

The service provides termination of pregnancy as a single speciality service; We inspected this service using our comprehensive inspection methodology. We conducted an unannounced inspection on 14 May 2019.

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.

Services we rate

We rated this service as Good overall.

We found the following areas of good practice:

  • The service provided mandatory training in key skills to all staff.

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.

  • Staff controlled infection risk well. Staff kept equipment and the premises visibly clean. They used control measures to prevent the spread of infection.

  • The service had suitable premises and equipment and looked after them well.

  • Staff completed and updated risk assessments for each patient.

  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

  • Staff kept detailed records of patients’ care and treatment.

  • The service followed best practice when prescribing, giving, recording and storing medicines.

  • The service managed patient safety incidents well.

  • The service provided care and treatment based on national guidance and evidence of its effectiveness.

  • Staff assessed and monitored patients regularly to see if they were in pain.

  • Managers monitored the effectiveness of care and treatment and used the findings to improve them.

  • The service made sure staff were competent for their roles.

  • Staff of different kinds worked together as a team to benefit patients.

  • Staff promoted sexual health in line with national guidance.

  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the service policy and procedures when a patient could not give consent.

  • Staff cared for patients with compassion and provided emotional support to patients.

  • Staff involved patients’ decisions about their care and treatment.

  • The service planned and provided services in a way that met the needs of local people and considered individual needs.

  • Patients could mostly always access care and treatment in a timely way

  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.

  • Managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care.

  • The service had a vision for what it wanted to achieve and workable plans to turn it into action.

  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

  • The service systematically improved service quality and safeguarded high standards of care.

  • The service had good systems to identify risks, plan to eliminate or reduce them, and cope with both the expected and unexpected.

  • The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.

  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.

  • The service was committed to improving services.

However, we also saw some areas where the service could improve:

  • Two out of five of the patient files we reviewed did not contain a competed VTE risk assessment.

  • Staff used both paper and electronic patient records which staff said could be time-consuming.

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

Nigel Acheson

Deputy Chief Inspector of Hospitals

19 May 2016

During a routine inspection

BPAS Birmingham Central is part of the national charitable organisation British Pregnancy Advisory Service (BPAS).

The service was registered as a single speciality termination of pregnancy service. BPAS Birmingham Central provided consultations and medical terminations of pregnancy up to 10 weeks gestation. It provided support, information, treatment and aftercare for people seeking help with regulating their fertility and associated sexual health needs. Its main activity was termination of pregnancy.

We carried out an announced inspection of this service on 19 May 2016 and attended. This formed part of the first wave of inspection of services that provide a termination of pregnancy. This inspection was carried out using the Care Quality Commission’s methodology.

To get to the heart of patients’ experiences of care, we always ask the following five questions of every service and provider:

  • Is it safe?

  • Is it effective?

  • Is it caring?

  • Is it responsive to peoples’ needs?

  • Is it well-led?

Are services safe at this service

  • The service had a culture of safety. Staff reported incidents and incidents were logged, investigated and learned from.

  • Quality and safety audits were completed by the clinic and submitted monthly to the regional clinical lead.

  • Staff followed procedures in place for good hygiene and control of infection, safe storage and administration of medication, safeguarding children and vulnerable adults, assessing and responding to clinical risk for patients and record keeping.

  • There were sufficient nurses and doctors available to treat patients.

  • Staff were aware of their duty of candour responsibility.

  • One area of the clinic used solely by staff could not be effectively cleaned for control of infection.

Are services effective at this service

  • Treatment was based on up to date good practice and staff followed policies and procedures.

  • Managers regularly audited clinical practice to maintain good standards of patient care and continuously improve outcomes for patients.

  • Staff were competent, well trained and experienced with access to information systems. They worked collaboratively for the benefit of patients.

  • Staff gave patients good information on which to base their decisions and spent time explaining options and procedures.

  • The service did not participate in any relevant local audit programme or peer review to bench mark its outcomes against other similar provider services. The provider told us it took whatever opportunities to bench it was offered by NHS services.

  • There was not a clear best interest decision making protocol in practice for women with learning disabilities who may need it or signposting to an independent advocacy service.

Are services caring at this service

  • Staff in all roles treated patients and those close to them with kindness and respect and put them at ease.

  • Nurses asked about and respected patients’ wishes about sharing information with a partner or family members or carers.

  • Nurses checked along the way that patients were sure of their decision. Additional information and counselling could be offered or the procedure postponed if they were unsure.

  • BPAS offered ongoing counselling support to all patients and patients under 18 years old were counselled prior to treatment as a matter of policy.

Are services responsive at this service

  • The clinic opened six days each week and was situated in the city centre near to transport links.

  • Patients could book appointments through a national telephone service that ran a flexible appointment system to offer as much choice as possible to patients.

  • Patients were generally offered an appointment within seven calendar days of contact with the service and seen promptly when they arrived at the clinic. Most patients had their procedure within 10 working days of making a decision to proceed.

  • Translation services were available and there was a free ongoing counselling service for patients.

  • The clinic encouraged patients to give feedback on the service.

  • Access to this clinic was difficult for patients with disabilities and means to support patients with a learning disability to understand and give informed consent to procedures were limited.

Are services well led at this service

  • Staff were committed to the BPAS vision of women being in control of their fertility.

  • The provider had an effective governance framework for reviewing the quality and safety of care. Performance and quality data such as incidents, complaints, policy and legislative updates were discussed at national and regional meetings.

  • Clinic performance was measured through audits and reported on a monthly dashboard to the regional operations director. Action plans were developed for areas that required improvement.

  • The clinic was well run by a manager registered with the CQC and staff felt confident about speaking up, learning from incidents and trying out new ways to improve the service. The registered manager had easy access to directors in the organisation for support and advice.

  • Staff encouraged patients to give feedback about the service they received and contribute to improving the service.

We saw several areas of good practice including:

  • The provider organisation had consulted a sample of young people in designing the safeguarding risk assessment. This improved the effectiveness of questions to identify young women who were isolated, at risk of abuse or exploitation.

However, there were also areas in which the provider needs to make improvements.

Importantly, the provider must:

  • Ensure that protocols are put into practice for obtaining consent for all patients including access to best interest decisions for those who may lack capacity to consent, including such patients with learning disability.

In addition the provider should:

  • Put in place a local contingency plan for business continuity in the case of prolonged loss of premises due to major incident.

  • Review the environment of the staff locker room and make improvements where necessary to ensure effective cleaning of the surfaces and floors.

  • Consider participating in relevant local or national audit programmes or peer review to bench mark outcomes against other similar provider services.

  • Ensure that where patient’s consent to simultaneous administration of abortion medication for medical abortions, they are clearly informed this method could increase the risk of failure.

Professor Sir Mike Richards

Chief Inspector of Hospitals

18 July 2013

During a routine inspection

We spoke with three people who were using the service on the day of our inspection, a relative and staff that supported them. People told us that they were happy with the care, treatment and support they received at the clinic. A person using the service told us, 'Today has been a positive experience.'

People told us that they had been fully involved in the decision to use the service. They told us that they had made decisions about the treatment they received after staff had explained their care, treatment and support choices to them. People also told us that they had been given time to consider the information prior to treatment so that they had the option to withdraw their consent if they wanted to. A person using the service told us 'I have received all of the information and staff have left it totally up to me to decide if I want to go ahead with the treatment or not.'

People told us that they were listened to and treated with respect by staff working at the clinic. People using the service told us, 'Staff have been very respectful to me. They have gone beyond what I would have expected,' and, 'Staff have been brilliant. They have taken their time and my appointment has not been rushed.'

Arrangements were in place so that people using the service were protected against the risk of abuse. This included arrangements for both adults and children.

Systems were in place to identify and monitor the quality of the service provided at the clinic and to manage risks to people's safety, health and welfare. People using the service were involved in this process, so that they had opportunities to discuss the quality of service they received.

During our inspection, we asked the local authority commissioning team about the quality of service provided at the clinic. They told us that they did not have any concerns about the quality aspects of the service.

15 November 2012

During a routine inspection

People using the service told us that they were happy with the care they received at the clinic. They told us that their care and support needs were being met. Comments included: 'I have no concerns whatsoever with the treatment I have had here' and 'Staff are really friendly, they are really easy to talk to and are very supportive.'

People told us that staff explained their care, treatment and support choices to them. This meant that they had the opportunity to be involved in making decisions about their care. A person using the service told us 'The staff have explained everything to me. They have explained what procedures I can choose to have.'

People told us that they were listened to and treated with respect by staff working at the clinic. They told us that their dignity had been respected. A person using the service told us 'Staff haven't judged me. They have treated me with respect.'

During our inspection, we asked the commissioning team at the local primary care trust about the quality of the service the clinic provided. They did not have any information to share with us about the quality aspects of the service.

20 March and 18 September 2012

During a themed inspection looking at Termination of Pregnancy Services

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.