The Care Quality Commission (CQC) has carried out a review of governance and leadership at the British Pregnancy Advisory Service (BPAS) to follow up on areas identified as needing improvement at a previous inspection in 2023.
The follow up review, took place in April 2024 and found progress with evidence of action taken to strengthen oversight of risk and better support staff in their delivery of care.
BPAS provides reproductive healthcare and termination of pregnancy services to women and people of childbearing age and operates across the UK. It has 49 clinics in England which fall into scope of CQC regulation.
Last year a CQC provider well led assessment identified some areas where the organisation’s governance processes lacked rigour and concerns that clinical and corporate risks were not always recognised or effectively managed. CQC issued a formal warning notice requiring BPAS to take action to address these issues as a priority.
Inspectors re-visited BPAS’s administrative headquarters in Warwickshire on 16 April 2024 to assess the actions taken since the previous inspection. They examined evidence supplied by the provider, looked at a range of performance data, and reviewed information shared by people using the service, the public and other organisations. They found significant improvements had been made with action taken to meet the requirements of the warning notice. The notice was therefore removed.
Inspectors found that:
- A new executive leadership structure had been put in place to ensure greater clinical expertise at a senior level to support the delivery of high quality care across all services.
- Governance arrangements and their purpose were better understood across the organisation and clearer lines of accountability had been established between the executive team and the board of trustees.
- Improvements had been made to the flow of information at a corporate level with evidence of operational issues and performance data discussed and scrutinised by the board of trustees.
- The organisation had updated its fit and proper persons requirement (FPPR) policy to include appropriate recruitment checks for staff in all roles and to comply with the recently launched NHS England FPPR Framework.
- Incident reporting processes had been strengthened to ensure greater transparency and there was increased clinical input into incident investigations. Improved routes to allow a more effective approach to reviewing incidents and identifying organisation wide learning has also been set up.
A full report detailing the findings of the follow up provider well led review has been published on CQC’s website.
CQC has not published a rating as a result of this focused follow up review.
As a result of the assessment CQC has told BPAS that it should take the following action going forward:
- Continue to ensure effective governance systems and processes are embedded across all services to support the delivery of sustainable and high-quality care.
- Continue to ensure policies and procedures are consistent across all services to support staff in the delivery of care and treatment and to allow effective audit and assurance.
- Continue to ensure that clinical and corporate risks are identified and effectively managed at every level in the organisation including a clear risk escalation process.
All services provided by BPAS are subject to ongoing monitoring and future assessment.