The Care Quality Commission
  • Hospital
  • Independent hospital

Archived: Marie Stopes International Sandwell

Glebefields Health Centre, St Marks Road, Tipton, West Midlands, DY4 0SN 0845 300 8090

Provided and run by:
MSI Reproductive Choices

All Inspections

24 and 26 July 2017

During a routine inspection

Marie Stopes International (MSI) Sandwell is operated by Marie Stopes International. MSI Sandwell was registered with the Care Quality Commission (CQC) in October 2010. The MSI Sandwell location holds a licence from the Department of Health (DH) to undertake termination of pregnancy services in accordance with The Abortion Act 1967.

Sandwell location provides medical and surgical abortion, contraception, face-to-face counselling, and screening for sexually transmitted infections. Services are provided to NHS-funded patients referred by local clinical commissioning groups, as well as private patients.

Facilities at the MSI Sandwell location include a surgical treatment room, a room used for recovery and preparation, and a consulting room. Patients waited in the shared waiting area until called through for consultation, after this they waited in a small waiting area outside the main treatment room.

We inspected this service using our comprehensive inspection methodology. We carried out the unannounced part of the inspection on 24 July 2017, along with a short notice announced visit on 26 July 2017.

We observed activity, including staff interaction with patients, and He checked the environment and equipment. We spoke with two medical staff on the five nursing staff, two reception staff, and two managers .We reviewed 28 sets of records and spoke with five patients. Before and after the inspection we reviewed information about MSI Sandwell.

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.

Services we do not rate

We regulate termination of pregnancy services but at the time of the inspection we did not 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 issues that the service provider needs to improve:

  • Out of 16 Termination of Pregnancy Early Warning Scores (TEWS) forms reviewed, two were completed correctly in accordance with the guidelines for completion of TEWS.

  • The provider supplied mandatory training figures, which showed that safeguarding, manual handling, consent, advanced life support; basic life support, incident reporting, medical gases and scanning training did not meet the provider’s own targets. The provider did not offer supervision.

  • The provider supplied mandatory training figures for infection prevention and control (IPC), which showed targets for IPC training had not been met by clinical and non-clinical staff. Therefore, we could not be assured that staff were able to apply basic IPC practices.

  • Handwashing and the wearing of gloves were variable in the preparation/recovery room and the consultation room.

  • The provider told us that medical gases training was provided both electronically and as part of a three day anaesthetic and recovery training course. We saw that 87% of eligible staff had attended the anaesthetic and recovery training course. The training matrix however included medical gas training separately which showed that only 4% of eligible staff had completed it. Therefore, we could not be assured that the training matrix was kept up to date.

  • Staff had only checked the major haemorrhage pack once ever.

  • The recovery room was small with very little space between patients; this made it difficult for staff to manoeuvre around patients to perform nursing care, and for staff to move the patients’ bed from the treatment room into the recovery room after their procedure.

  • Recording of Oromorph (a controlled drug morphine base) was inaccurate, there were no initials on amendments, and there were two different entries within the controlled drug register. Calculation of the remaining Oromorph appeared to show that 100 mls was possibly missing. We raised this at the time of inspection and the provider took immediate action to look into the matter.

  • Managers told us that paper held records that were transferred to and from other MSI locations should be taken by courier to ensure their safe and secure delivery. However, staff told us they transported records to and from other MSI locations using a sealed secure bag, then styles. We raised this with the regional director at the time of inspection who said they would take immediate action to ensure staff did not do this.

  • On the day of the announced inspection, we found two folders with patients’ identifiable information out on top of the cabinet.

  • We saw a patient could not have their surgical procedure on the day due to four patients attending for surgical termination. This was because there was a limitation on the number of people who could be cared for in the preparation /recovery room .There was no risk assessment completed on the day to decide which patient should be cancelled based on gestation. The service could not offer the patient another appointment until 23 weeks gestation. We wrote to the MSI nominated individual and asked for assurance of how the provider ensured these patients were subsequently safely treated, the patient had the procedure carried out within the lawful gestation period.

  • We saw one patient who was displaying challenging behaviour towards staff. The provider told us that while they had a policy on conflict resolution this policy did not cover this aspect of behaviour. They planned to address this issue. We noted that only 17% of staff had training in conflict resolution. Therefore, we were not assured that staff were enabled to manage these issues.

  • There was no provision of easy read documentation for people with learning disabilities. Staff told us they did not have any training or guidelines on communicating with people with learning disabilities.

  • At the time of inspection the clinical operations manager identified three potential areas of risk however, these were not listed on the locations risk register.

  • Early opportunities to learn from the March 2017 incident of haemorrhage and delayed emergency transfer to an acute service were missed.

However, we found the following areas of good practice:

  • Staff knew how to report incidents and described that they got an email response containing the outcome of the incident investigation.

  • The provider had a policy on female genital mutilation (FGM) which was in date. Staff asked patients at the consultation for both medical and surgical termination about this. This was documented on the individual patient safeguarding form. Staff knew to report this to the safeguarding lead and the police if the patient was less than 18 years of age.

  • As of 17 August 2017 child sexual exploitation (87%) and PREVENT (88%) training levels met the provider standards of 85%. FGM training level was 84%

  • We saw decontamination procedures carried out after each surgical procedure in the treatment room. The provider loaned theatre packs and decontaminated and packaged instruments in accordance with Health Technical Memorandum01-01 decontamination of surgical instruments.

  • The staff members who carried out the consultations on the day of the termination checked the electronic record for completeness and accuracy before they took the patient through to wait for their termination.

  • Treatment was managed in accordance with the Royal College of Obstetricians and Gynaecologists (RCOG), including gestation limit for the types of treatment provided.

  • Anaesthetic arrangements were in accordance with the Royal College of Anaesthetists (RCoA), Association of Anaesthetists of Great Britain, and Ireland (AAGBI).

  • We observed staff talking with patients and giving contraception where required.

  • Doctors and nurses administered pain relief in line with best practice. For example, staff offered patients nonsteroidal anti-inflammatory drug (NSAIDS) routinely, which is recognised as best practice.

  • MSI had implemented a bespoke ultrasound training course to date pregnancy provided by a qualified external sonographer delivered in line with the requirements of MSI policy.

  • We saw nurses explained the procedure, possible risks, and alternative options before taking written consent from patients at all times. Nurses asked patients if they wished to continue right up to the point of the termination.

  • Staff were supportive and showed empathy when they talked with patients. One patient told us that the nurse held her hand all the way through because she was so nervous about the surgical termination. Another patient who originally went for a medical termination became very upset when she realised that the process would commence at home, was comforted by the nurse, who then discussed changing to a surgical termination, which the patient decided to do.

  • At reception, staff were responsive to patients in relation to their identification. The services reception was directly adjacent to the GP service reception, therefore, staff confirmed patients’ identification by using the first name only, and second part of their postcode. They also spoke in a hushed manner and wrote the answers to questions on paper rather than verbalising them if it was sensitive information.

  • The MSUK vision that women be in control of their fertility was visible and clear in the clinics information and articulated by staff in all roles who, we found were committed to this.

  • The provider organisation had a system in place for checking the registration of nurses and doctors and insurance for practitioners, the operations manager told us they receive a three months’ notice prompt for when they these are due for review.

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, even though a regulation had not been breached, to help the service improve. We also issued the provider with one warning notice and four requirement notice(s). Details are at the end of the report.

Heidi Smoult

Deputy Chief Inspector of Hospitals

8 June 2016

During a routine inspection

Termination of pregnancy (ToP) refers to the treatment of termination of pregnancy by surgical or medical methods. Marie Stopes International Sandwell is part of the provider group Marie Stopes International (MSI). The service at MSI Sandwell was located within a purpose built neighbourhood health care centre shared with other health care service providers. The services are provided under contract with local clinical commissioning groups for NHS patients. MSI Sandwell also accepts private patients.

The service was registered in November 2010 as a single specialty termination of pregnancy service providing a range of services for medical termination of pregnancy up to a gestation of 10+0 weeks and surgical termination of pregnancy up to 23+6(days). This included: pregnancy testing, unplanned pregnancy counselling/consultation, early medical abortion, abortion aftercare, sexually transmitted infection testing, contraceptive advice and contraception supply and vasectomy services. The Sandwell service had no ‘satellite’ clinics attached to its registration.

We carried out this announced comprehensive inspection on 8 June 2016, as part of the first wave of our 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. We have not rated this service because we do not currently have a legal duty to rate this type of service or the regulated activities it provides.

The inspection team included two inspectors and a consultant obstetrician and gynaecologist supporting the inspection by phone.

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 people’s needs?
  • Is it well-led?

Our key findings were as follows:

Are services safe at this service

Staff reported incidents but the systems that supported this were not reliable and investigation and learning was variable. There was sometimes delay in uploading reports to the electronic system, staff could not easily track the progress of incident investigations and some patterns of incident reported were not identified and investigated. Staff did not consistently follow some safety systems such as national guidelines to safer surgery, use of emergency equipment checklists and good hand hygiene practices. Not all staff were up-to- date with their mandatory training including safeguarding, life support skills and supporting anaesthesia. Many staff including local leaders had not undertaken safeguarding training to the level appropriate for degree of vulnerability presented by many patients. Staff followed policies and procedures for safeguarding children and vulnerable adults. Risks to patients were assessed and staff made referrals and emergency transfers to local acute hospitals when it was appropriate for patients. Sufficient numbers of experienced doctors and nurses staffed the service.

Are services effective at this service

Systems in place that collect information about the effectiveness of the services did not provide the local leaders or staff with a clear picture of how their service was performing against regional and national clinical standards. Clinical audits recommended by the Royal College of Obstetricians and Gynaecologists were not specifically addressed. The results of local audits did not always match with what we observed or the patterns of errors shown on the provider’s incident reporting records.

There was no established pathway for effectively supporting women with learning disabilities to give informed consent to treatment. Staff checked patient’s medical and health history before treatment and the clinic only carried out procedures for which it was registered and within national guidelines. Other patients were referred to more appropriate services to meet their needs. Patients were given information about contraception and sexually transmitted infection. Nurses and doctors were competent and worked with other healthcare providers locally for the benefit of patients.

Are services caring at this service

Most staff treated patients with respect, kindness, dignity and care. Patients spoke positively about staff attitudes towards them. However we observed some surgical staff showed impatience with one patient with learning disabilities; did not greet or address patients when they entered theatre and clinical staff discussed other patients in the presence of a patient who was under anaesthetic. Patients received a lot of information from staff about their treatment and a 24-hour help line was available to provide additional information and address concerns. Staff checked patients decisions at each stage of the process and went over the options with patients on more than one occasion. Counselling was made available to all patients over the phone or face-to-face by independent counsellors. The provider’s policy was this was compulsory for patients under 16 years of age. There was no ‘easy read’ additional material available to enable patients with learning disabilities to access the information about treatment, treatment options and contraception.

Are services responsive at this service

Services were planned to provide surgical and medical terminations of pregnancy within a purpose built accessible neighbourhood health care centre. Patients accessed services and appointments through a national call centre. This system managed waiting times across clinics to respond flexibly to local demand, legal requirements and targets set by commissioners of the services. Translation services were available to patients from the first point of making contact with the organisation and staff helped patients to access other services for help with domestic violence or drug abuse. Patients could receive counselling prior to receiving any procedures. There were a variety of means by which patients could comment on the service, raise concerns or make a complaint. Waiting times within the clinic was a challenge for the service and patient satisfaction regarding this had fluctuated during 2015/16. There were no specific arrangements to support gaining informed consent from adult patients with learning disabilities.

Are services well led at this service

The provider had a clear philosophical and political vision for the service and all staff were committed to this and highly motivated. The clinic was led by a manager registered with the Care Quality Commission and staff felt well supported by the local leadership team. The views of patients were routinely sought; there was engagement with the wider public and other professionals locally. The organisation aimed to improve by trying out new ways of providing the service. Some clinical staff showed a defensive attitude to critical feedback. This was acknowledged by local leadership; it was reflected in the leadership of the organisation and was a characteristic of the culture of the organisation. Organisational structures in place to ensure legal compliance, manage risk and monitor quality had weaknesses that meant some risks, repeated mistakes and serious incidents were not properly dealt with and learned from.

We saw one area of outstanding practice:

  • Reception staff were highly skilled at putting patients at their ease and discretely confirming personal and private details when patients arrived including within areas shared by other service providers.

However, there were also areas of where the provider needs to make improvements.

Importantly, the provider must:

  • Ensure all staff treat patients with respect and uphold their dignity at all times including in the theatre environment and when they need extra support over consent.
  • Put in place an effective incident reporting system that can provide assurance the provider can consistently learn from incidents and error, notify incidents to the appropriate authorities and exercise its duty of candour requirement.
  • Ensure all relevant staff are up-to-date with mandatory training.
  • Ensure all appropriate staff undertake safeguarding children and adults training at level three competency.
  • Take steps to ensure clinical staff consistently follow good hand hygiene practices.
  • Ensure staff follow properly national guidelines to safer surgery.
  • Ensure staff use emergency equipment checklist systems effectively.
  • Put in place protocols for obtaining consent, pathways and support for all patients who may lack capacity to consent, including those patients with a learning disability.
  • Ensure clinical audits recommended by the Royal College of Obstetricians and Gynaecologists for termination of pregnancy are undertaken in order to continuously improve the services offered by the clinics and provide feedback effectively to staff about the services clinical performance.
  • Improve the reliability of local clinical and safety audits of the clinics.
  • Ensure arrangements are put in place to support the specific needs of patients with learning disabilities to understand the information about the procedures and to support getting informed consent for treatment from learning disabled adult patients.
  • Review the governance arrangements in place to provide more effective assurance and auditing systems or processes. These must assess, monitor and drive improvement in the quality and safety of the services provided, including the quality of the experience for people using the service. The systems and processes must also more effectively assess, monitor and mitigate any risks relating the health, safety and welfare of people using services and others. Continually evaluate and seek to improve governance and auditing practice.

In addition the provider should:

  • Explore methods of giving patients with learning disabilities access to information about the service and their treatment so they can have a better understanding and be fully involved.

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 11 Consent

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

Regulation 13 Service users must be protected from abuse and improper treatment in accordance with this regulation.

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 enforcement action taken 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

20 August 2013

During an inspection looking at part of the service

During our inspection of this service in June 2013 we found non-compliance with medication management. We found that controlled medication had not been secured, some medication items had passed their expiry date and checking processes were not adequate regarding the temperature monitoring of rooms where medication was stored. We carried out this inspection to find out if improvements had been made and found that overall they had.

19 June 2013

During a routine inspection

This inspection was unannounced so no one knew we would be visiting that day. Surgical procedures were being undertaken on the day of our inspection so we were able to assess service provision concerning this.

During our inspection processes we spoke to five people who were using this service. People told us that they were happy with the service that had been provided and the treatment they had received. One person told us, 'I am really satisfied with the whole service and processes'. Another person said, 'The staff have been very kind. I do not feel like I have been judged'.

We saw that people were given a full explanation about their planned treatment and that they had consented to their treatment.

People we spoke with and records confirmed that appropriate questions and screening had been undertaken to prevent risks to people's physical and mental health.

We found that improvements regarding the medication safety were needed as medication was not all secured as it should have been.

Staff were supported to ensure they had the skills and knowledge to meet the needs of the people using the service safely.

Processes were available for people to make complaints and for any complaints to be looked at and dealt with

19 February 2013

During a routine inspection

This inspection was unannounced so no one knew we would be visiting that day. No surgical procedures were being undertaken on the day of our inspection so we were unable to assess service provision concerning this.

During our inspection processes we spoke to three people who were using this service. People told us that they were happy with the service that had been provided and the treatment they had received. One person told us, 'Everything has gone well. The staff have all been very good'. Another person said, 'The service has been good'.

We found that people had been given a full explanation about their planned treatment and that they had consented to their treatment.

People we spoke with and records confirmed that appropriate questions and screening had been undertaken to prevent risks to people's physical and mental health.

We saw that processes were in place to maintain adequate cleaning and to promote infection prevention.

Recruitment processes were robust and gave assurance that only suitable staff had been employed.

We saw that processes were in place to monitor the quality of the service provided to benefit the people who used it.

23 March 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.