Window to the Womb Portsmouth

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This is the first assessment for this service. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. However, there were some areas of the governance process which were not always used effectively to drive improvement within the service.

We found that the service was in breach of regulation for good governance.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff consistently reported high levels of motivation and positivity about their roles. They described a culture that was friendly, safety-focused, and open, and stated they received strong support from managers. Teamwork was described as effective, and the working environment as encouraging. The service prioritised creating a warm and welcoming environment. Staff worked closely with NHS teams to ensure people at risk or with urgent needs received appropriate care.

Leaders completed an annual audit and quality check to support continuous learning and quality assurance.

Leaders had clear organisational vision, underpinned by the franchise’s ethos. At a local level, managers explained their plans to extend the clinic, by expanding their clinical ways of working and were actively monitoring progress. We observed managers interacting positively with patients and families during our visit.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The service followed a traditional organisational structure with clear responsibilities and a transparent chain of command. One managing director shared responsibility for the clinic, a senior management team, including the registered manager and area manager oversaw operations within other locations including this one together. Staff and managers told us that the area manager was available at short notice.

Registered manager and area managers played a key role in day-to-day operations. They endured teams were briefed. Monitored clinic managers who were onsite, completed compliance checks, checked rota, and responded to tasks set by leaders.

There had been no staff related complaints in the past 12 months, and no staff had taken sickness absence due to workplace injury.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service maintained an open culture that encouraged staff to raise concerns without fear. The service had a Freedom to Speak Up (FTSU) policy and guardian positioned, both of which were accessible to all staff. The policy clearly outlined how staff could raise concerns and what they could expect in response, promoting transparency and support.

The service also had a whistleblowing policy that enabled staff to raise concerns confidentially with any members of the management team. Managers we spoke with understood their responsibilities when handling whistleblowing concerns, and staff said they felt confident the senior leadership team would respond appropriately.

The team was small, including managers, and because of that, we were able to observe the close working relationships within a culture that valued everyone’s contributions. Staff told us that issues were rare and that they worked together effectively to resolves problems when they arose. The recent staff survey mirrored this.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff were compliant with a wide range of mandatory training modules, and these modules included Equality, Diversity and Inclusion (EDI) training. There was a dedicated, up to date policy created by the franchise.

Staff told us they felt there were equal opportunities for career progression and promotion regardless of background or protected characteristics

We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We identified concerns in governance systems and documentation across several areas of the service. Leaders did not always manage risks effectively or maintain clear oversight of performance.

Although the service maintained a risk register, staff did not consistently use systems and processes to identify, record and monitor risks. We reviewed the risk register dated January 2025. The register identified two highest-priority risks: machine failure and ambulance non-attendance during an emergency. However, records lacked key governance information for both risks. The register did not record when staff identified the risks, when leaders last reviewed them, or their current status, such as whether they remained active, ongoing or resolved.

This meant leaders could not demonstrate that they reviewed higher-rated risks regularly or reassessed risk scores to ensure they remained appropriate. Records also did not show whether staff tested or reviewed mitigating actions. As a result, leaders could not demonstrate clear oversight of risks or show how they mitigated them in a timely way.

The service recorded 6 risks in total on the risk register. However, leaders could not provide evidence that staff discussed these risks during governance or risk meetings, demonstrating there was ongoing oversight and monitoring of risks and the effectiveness of their mitigations.

Policies did not always support effective governance. For example, the COSHH policy did not clearly state review timescales. This reduced assurance that staff reviewed risks associated with hazardous substances regularly. The Infection Control and Waste Management Policy stated that staff must store clinical waste securely to prevent access by the public, animals or pests and set out requirements for sharps bin disposal. However, staff did not consistently follow these requirements.

The Patient Support Policy described the use of professional translation services. However, staff did not understand how to access these services and instead relied on informal arrangements. Managers also lacked awareness of the risks associated with this approach prior to the inspection.

The service operated an audit programme that included monthly local audits, annual audits and peer reviews. However, leaders did not always use these audits effectively to identify risks or drive improvement. For example, audits had not identified the infection prevention and control (IPC) and COSHH concerns we found during the inspection. This meant leaders did not always identify or act on areas requiring improvement.

The service also did not audit women’s records to check whether staff identified and recorded women’s additional needs. This limited leaders’ oversight of care delivery and reduced opportunities to improve the service and women’s experience.

The service did not follow a structured approach to developing staff into management roles. Managers frequently recruited internally, with junior scanning assistants progressing to clinic manager roles and clinic managers progressing to area manager roles. However, the service did not provide a formal management training programme. Staff development relied on one-to-one support, observation and informal learning. This resulted in inconsistency in how managers carried out key responsibilities, including staff appraisals.

Leaders had also not ensured that staff reported all serious incidents to relevant external agencies, including the Care Quality Commission (CQC). Staff described an incident involving racist behaviour that they reported to the police but did not notify CQC. Managers told us they were unaware of the requirement to notify the CQC until inspectors explained this during the inspection. This indicated gaps in leaders’ understanding of regulatory responsibilities.

The service had developed an emergency policy and contingency plan to respond to scenarios such as staff absence, equipment failure and utility disruption. The franchise operations manager completed annual compliance audits and developed action plans in response to findings. The registered manager also carried out monthly clinic visits and shared performance data against key indicators with staff during team meetings.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The registered manager engaged with regional networks to better understand the local community needs and the franchiser’s ambitions.

The service worked with a local photographer to provide the images displayed in the clinic. It also partnered with two fertility companies that use them for scans and blood tests. Women's blood samples were sent to laboratories both of which the service maintained regular contact with to ensure it delivered the highest standard of care.

The service managed its social media platforms centrally and used them to share information. Staff told us this was an effective way to engage with the local community and promote the service.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The service used electronic patient feedback as a learning tool to improve patient outcomes. Leaders and managers contacted patients who rated their experience as four stars or below to understand concerns and identify opportunities for improvement. Managers regularly reviewed patient feedback in meetings to monitor themes and trends and acted where needed. This approach supported consistent outcomes and ensured care met both clinical standards and people’s expectations.