The Marie Stopes West London Centre is operated by Marie Stopes UK International, which is a specialist reproductive healthcare organisation and registered charity. The West London centre is based in Ealing.
The service provides medical and surgical termination of pregnancy services, screening for sexually transmitted diseases, contraception advice and counselling.
The service provides surgical terminations up to 23 weeks plus six days gestation, and medical abortions up to nine weeks plus four days gestation. They also perform non-scalpel vasectomies. The service treats NHS and private patients.
We inspected this service using our comprehensive inspection methodology under Section 60 of the Health and Social Care Act 2008. The provider was given 23 days’ notice of this inspection. We carried out the announced inspection on 6 and 7 July 2017. We also visited one early medical pregnancy unit (EMU) providing satellite services at Wembley on 6 July 2017. At the time of our inspection, the operations manager was in the process of registering as the registered manager with the CQC.
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?
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 that were relevant to this location, which we have followed up as part of this inspection.
The breaches were in respect of:
Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment
Regulation 17 HSCA (RA) Regulations 2014 Good governance.
Services we do not rate
We regulate termination of pregnancy 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:
- Processes and procedures for daily infection prevention and control (IPC) were in place with regular cleaning checks introduced.
- The policies in place to ensure optimum standards of care and patient safety had been updated and were in line with the latest guidance. Staff were able to access these easily.
- Staff on the ward were passionate about their job and believed in what they did. They spoke to patients in a manner in which they would like to be spoken to and were caring and compassionate.
- Staff communication with one another and with the public was good. Staff had a good understanding of safeguarding and female genital mutilation (FGM).
- We found management responsive to issues raised at the inspection and we found that managers had made improvements to processes since the last inspection.
- A revised audit programme had been introduced since the last inspection. We saw individual examples of improvements made and team meeting minutes included discussions of audit scores and arising actions.
However, we also found the following issues that the service provider needs to improve:
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Staff had variable knowledge of the duty of candour.
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Some staff expressed concern about the availability of training.
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Usage of the World Health Organisation (WHO) and ‘five steps to safer surgery’ checklist was not always consistent.
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Although improvements had been made to local governance this was hampered by some disjointed and poor communication from corporate management.
Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements to help the service improve. We issued a requirement notices in relation to the World Health Organisation (WHO) and ‘five steps to safer surgery’ checklist. Details are at the end of this report.
Amanda Stanford
Deputy Chief Inspector of Hospitals