Termination of pregnancy (TOP) refers to the abortion of pregnancy by surgical or medical methods. Marie Stopes UK International (MSI) Central London is part of the provider group Marie Stopes International, a not for profit organisation that was founded in 1976, to provide a safe, legal abortion service following the 1967 Abortion Act.
Marie Stopes International Central London was registered with the CQC in March 2012. It provides medical and surgical termination of pregnancy, consultations, ultrasound scans, and counselling and support for people who use the service. The provider offers vasectomy, performed under local aesthetic, long acting reversible contraception, well woman screening, well man screening and sexually transmitted infection testing and screening.
Two early medical units (EMUs), known as satellite locations, are situated at Watford and Hemel Hempstead in Hertfordshire. They provide medical termination and consultations in the early stages of pregnancy. All three locations hold a license from the Department of Health (DH) to undertake termination of pregnancy services in accordance with The Abortion Act 1967. Services are provided to both NHS and privately funded patients. Patients of all ages, including those aged less than 18 years are treated at all three locations.
Between January 2015 and December 2015 MSI Central London carried out 1057 surgical termination of pregnancy, and1090 early medical termination of pregnancy. In the same period MSI Hemel Hempstead carried out 504 early medical termination of pregnancy, and MSI Watford carried out 372 early medical termination of pregnancy.
We carried out this announced comprehensive inspection on 5-7 April 2016, as part of the first wave of inspection of services providing a termination of pregnancy service. The inspection was conducted using the Care Quality Commission’s new methodology. We have not provided ratings for this service. CQC does not currently have a legal duty to award ratings for those services that provide solely or mainly termination of pregnancy services; amendment to the current Care Quality Commission (Reviews and Performance Assessment) Regulations 2014 is required to enable us to do this.
The inspection team included an inspection manager, and three inspectors, two of whom who were also specialist advisers in midwifery and nursing, and a specialist advisor who was a consultant obstetrician and gynaecologist.
Our key findings were as follows: We highlighted areas for improvement in safety, effectiveness, caring, and well-led domains. We found the service to be responsive.
Are services safe at this hospital?
Safety was not always a sufficient priority because:
-
There was inconsistent reporting of safety concerns. None of the staff we spoke with, other than managers, could recall a time when they reported a safety incident and some staff were not clear about the procedures to follow.
-
A number of items of equipment used for the diagnosis and management of patient treatment and care was not subjected to safety or maintenance checks, particularly at the two EMUs.
-
There were omissions in safety checks for patients undergoing surgical procedures at the Central London centre and audit processes to monitor whether the surgical safety checklist was being used were not sufficiently robust.
-
National guidelines for infection prevention and control and cleanliness were not always adhered to. Requirements for cleaning, cleaning schedules, and checklists at all three locations were not met.
-
Not all staff completed mandatory training in safeguarding, moving and handling and life support. However, staff demonstrated a correct understanding of safeguarding of adults and children and could describe actions to be taken in cases of suspected abuse.
Is the service effective?
-
Treatment was not always compliant with RSOP10: Professional Guidelines, which requires providers to have regard to relevant and professional guidance. For example, MSI did not adhere to the Royal College of Obstetricians and Gynaecology (RCOG) guidelines for the management of medical termination of pregnancy up to 9 weeks and 4 days gestation, which recommends 24 – 48 hours between the administration of the medicines used to bring about termination of pregnancy.
-
Training specific for individual roles was provided to staff to ensure they were able to meet the needs of the patients they delivered care to. However, not all staff completed this training in a timely manner.
-
Policies were accessible to staff and were generally developed in line with Department of Health standard operating procedures and professional guidance.
-
Patients were offered appropriate pain relief, precautionary antibiotic treatments and post-termination of pregnancy contraceptives.
Is the service caring?
-
Privacy was not always achieved in the waiting area and recovery lounge at the Central London location.
-
Patients felt safe and well cared for and consistently reported about the non-judgmental approach of staff. Patients' choices were respected.
-
All patients had a chance to speak with a nurse privately to make sure that all questions were answered and they received appropriate support to make a decision. Women could be accompanied by someone who was close to them.
-
Patients’ emotional and social needs were valued by staff and embedded in their care and treatment.
Is the service responsive?
Is the service well-led?
-
There was insufficient oversight of the service and its delivery. We were not assured by the leadership within the service. MSI provided the centre with an integrated governance framework in line with the NHS governance agenda. However; arrangements for performance management were fragmented and did not always operate effectively.
-
Staff described and we observed the culture to be top down and directive. There were gaps between the governance at corporate and centre level. Managers were not included in policy development. For example, centre managers and staff were not fully aware of the rationale and evidence to support the introduction of simultaneous administration of medicines, and were not fully engaged in the process.
-
Corrective actions to manage risks were not sufficiently prioritised or resolved in a timely way by people with the appropriate level of authority. Where issues remained unresolved mitigating actions were not always in place.
-
Staff were not always clear of the audit processes and outcomes and the processes to identify, report and act on risks.
-
The senior management team at the centre and at regional level was made up of relatively new members of staff following some interim appointments. Staff commented on the previously high frequency of changes in leadership which created some instability. Staff were feeling more settled and spoke positively about the new management team.
-
The centre managers were seen by staff to be supportive, visible and approachable at the Central London centre. However, staff were unsure about the arrangements for managers to visit EMUs and there was no evidence of planned, regular visits. Staff were, however, satisfied with the managerial telephone support they could access if necessary.
There were also areas of practice where the provider needs to make improvements. Importantly the provider must:
-
Ensure policies are kept up to date and that relevant staff are involved in clinical policy development and review.
-
Ensure there are systems in place to keep staff informed and trained in relevant legislation, regulations and guidance
-
Improve local safety incident reporting and sharing of learning.
-
Provide formal root cause analysis training for staff involved in incident investigations.
-
Assess record and act upon risks for each location.
-
Provide effective systems for safety and maintenance equipment checks and equipment replacement.
-
Use the WHO safety checklists for all patients undergoing surgical procedures
-
To ensure audit processes to monitor whether the surgical safety checklist is used and acted upon are formally introduced, carried out and acted upon.
-
Enable effective management and governance to prevent and control infection and ensure medicines are managed correctly.
-
To ensure all of the national standards, including environmental, and cleaning requirements are adhered to.
-
Enable all staff to complete training that is necessary for them to fulfil their role(s), including safeguarding level three, delivering HIV testing results, and all mandatory training and relevant skills training.
-
Staff should routinely ask women about domestic abuse in line with current guidelines.
Action the provider SHOULD take to improve
-
Ensure environment provides privacy and dignity for patients using the service.
-
Display up to date and visible information about how to raise complaints and concerns at all three locations.
-
Ensure there is a formal agreement in place to support emergency transfers.
Due to the number of concerns arising from the inspection of this and other MSI locations, we inspected the governance systems at the MSI corporate (provider) level in late July and August 2016. We identified serious concerns and MSI undertook the immediate voluntary suspension of the following services as of 19 August 2016 across its locations, where applicable:
-
Suspension of the termination of pregnancy for children and young people aged under 18 and those aged 18 and over who are vulnerable, to include those with a learning disability
-
Suspension of all terminations using general anaesthesia or conscious sedation
-
Suspension of all surgical terminations at the Norwich Centre
MSI responded to the most serious patient safety concerns we raised and was able to lift the restrictions on the provision of its termination of pregnancy services at this location on 7 October 2016.
CQC has also undertaken enforcement action for breaches of the following regulations, which are relevant to this location:
-
Regulation 12 Care and treatment must be provided in a safe way for service users
- Regulation 17 Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part. (Good governance)
CQC is actively monitoring compliance with the above warning notices in order to ensure that services are operated in a manner which protects patients from abuse and avoidable harm.
Professor Sir Mike Richards
Chief Inspector of Hospitals