Window to the Womb Reading

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We found a service that focused on infection, prevention and control. The service had enough staff to meet women’s needs and staff were trained to keep women, and their families safe. The service provided robust systems and pathways to ensure smooth transitions between providers. However, safeguarding policies and processes were not in line with best practice, the hand washing area was not risk assessed and learning and follow-up from incidents was not documented.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s experience

Score: 3

People who used the service advised us they felt if there was an incident, it would be taken seriously and investigated appropriately.

Feedback from staff and leaders

Score: 3

All staff we spoke with understood how to use the online reporting system, their responsibilities in reporting incidents and near misses and Duty of Candour, the legal duty to be open and transparent. Staff could describe changes to practice as a result of a complaint. When changes to policy or practice were made, the manager had a system where staff signed off to state they understood the changes.

Processes

Score: 2

We found some gaps in the governance of incidents. Documentation did not include next steps and follow up. All staff we spoke with knew what steps had been taken, however this information was not included within incident files. For example, we saw an incident form detailing that a member of staff had burned themselves on the kettle in the staff kitchen. There was no further detail as to whether any first aid was provided, whether the kettle was portable appliance tested or whether a new kettle was purchased.

There was cross site learning from incidents and complaints. Managers shared details of incidents, and learning and changes were discussed during team meetings.

People’s experience

Score: 3

People we spoke with advised us there was good communication between the service and their NHS maternity team, regarding scan results and information.

Feedback from staff and leaders

Score: 3

Managers demonstrated that Window to the Womb locations used the same systems and processes including communication channels. This ensured sonographers had access to support if they required help reviewing a scan.

Feedback from partners

Score: 3

The local NHS trust advised us they had no issues or concerns regarding this service.

Processes

Score: 3

Staff completed daily quality assurance checks for the ultrasound machine to ensure it was safe to operate. Due to the nature of the service, they did not require a resuscitation trolley. We saw a sealed and in-date first aid box and rotas ensured someone was always on duty who had adult and children first aid qualifications. In the case of an emergency, staff understood they were required to call 999.

People's experience

Score: 3

People were aware of the safeguarding posters and leaflets displayed around the clinic, including those in the toilets for a national domestic violence charity.

Feedback from staff and leaders

Score: 2

All staff had completed the required level of safeguarding adult and children training. However, staff told us they would share any concerns with the manager who would decide whether or not to make a referral. This was not in line with best practice, where anyone should feel empowered to make a referral.

Staff understanding of modern slavery was only from an employee perspective, and not from a patient perspective. However, staff knew who the service Safeguarding Lead was, and all had good understanding of recognising Female Genital Mutilation (FGM) and how to report it. Staff were also up to date with training in supporting women and families with learning disabilities, this included Oliver McGowen training and Mental Capacity Act training. Oliver McGowen training was developed to support better understanding of autism. Staff now had training in child sexual exploitation, and this was referenced in the services policies.

Processes

Score: 2

We viewed the services safeguarding children and adults' policy and noted that whilst they were now site specific, there was repeated information in both policies, some of which was not applicable. Information on how to make a referral was available to staff. However, it was not included within the policy. Therefore, it could easily be missed resulting in a safeguarding concern, potentially not being referred or investigated appropriately. The manager created a list of safeguarding topics that were discussed at staff meetings.

People’s experience

Score: 3

Women we spoke with were aware they could not have more than one scan every two weeks and that they could not have a scan during the 18–21-week window, so as to not impact with the NHS provided 20-week anomaly scan.

Feedback from staff and leaders

Score: 3

Staff were aware of their role and responsibilities in recording and documenting the type of, and frequency of scans and advising women of the possible effects of over exposure to ultrasound. Scanning time was restricted to 10 minutes in accordance with the British Medical Ultrasound Society (BMUS) guidelines. Staff also followed the ‘As Low As Reasonably Achievable’ (ALARA) principles, in line with Society and College of Radiographers (SCOR) ‘Guidelines for Professional Ultrasound Practice’ 2017.

Processes

Score: 3

The service did not scan women under the age of 16. Those attending under the age of 18 were accompanied by an adult who provided identification and evidence as to their relationship with the individual in attendance. This was to ensure young women received both emotional and physical support whilst on-site. Staff no longer looked after children whilst women were attending their appointments.

People's experience

Score: 2

People felt the new clinic was welcoming and spacious. However, we received some negative comments regarding the location of the computer where women and couples could view and choose their photos. This was in a cramped corner of the waiting room. Although the screen was facing outwards, the furniture was arranged in order that staff and members of the public could not see what couples were looking at. However, people advised us they would prefer either a private room or that the desk be rearranged.

Feedback from staff and leaders

Score: 3

Following a move to new premises, staff reported they now had more space.

Observation

Score: 2

The service had a hand wash sink in the treatment room; however, it was not a clinical sink and therefore did not comply with legislation. Management advised us they were unable to make structural changes to the environment due to their contract with the building owners. However, the risks associated with the site were increased as the service also provided invasive procedures such as bloods and transvaginal scans, rather than solely non-invasive over the skin ultrasounds. The service did not have risk assessments, procedures or audits to ensure the sink was solely dedicated as a hand wash area. Therefore, the sink area was not in line with `Health Building Note 00-09' legislation.

The reception computer backed on to the computer used by women and families to view their scanning images. This had been risk assessed, and the reception computer monitors had filters, in order that you could only view the screen if directly in front and within two feet.

Processes

Score: 3

The clinic had a dedicated room where difficult conversations could take place outside of the scan room but still in a private setting. The service had a full bank of environmental audits including ensuring fire extinguishers were full, in date and located appropriately as well as a log of fire alarm testing and evacuation practice. The service also had up to date documentation on Legionnaires testing and evidence of the managers competency training. All equipment was labelled with up-to-date portable appliance testing and scanning equipment including probes had up to date servicing and were calibrated according to manufacturer's guidelines.

People’s experience

Score: 3

People who used the service advised us they were happy with the number of staff available at the service. Women were especially happy that there was a chaperone present for every appointment.

Feedback from staff and leaders

Score: 3

Staff advised us they had all received an appraisal in the 12 months prior to inspection. Staff stated they were allocated time to prepare for appraisals and they were used as an opportunity for learning and reflection and included meaningful discussions regarding career progression.

Observation

Score: 3

There were enough staff to ensure the effective running of the service on the day we visited. We saw the staff rota; this was based on the planned number of scans booked and was available a month in advance. The planned staffing levels matched actual and there were contingency plans for sickness and annual leave. The manager showed us mandatory training completion records, which demonstrated 100% of staff were up to date with training. Training was a mixture of online and face to face.

Processes

Score: 2

The service did not meet all prerequisites as outlined in recruitment legislation. We checked all staff files and noted that none contained a pre-employment mental and physical health questionnaire in line with specification 8 of ‘Schedule 3’ guidelines. Therefore, management could not provide assurances that reasonable adjustments had been made to support staff working at the service.

We saw evidence that sonographers and clinical leads received training on having difficult conversations and all staff had evidence of training in recognising signs of poor mental health.

People’s experience

Score: 3

People were happy with the level of cleanliness at the service.

Feedback from staff and leaders

Score: 3

Staff advised us that the manager was very observant regarding the cleanliness of the service, and all areas of the clinic were inspected daily before scanning lists began.

Observation

Score: 3

We checked all areas of the clinic, including high and low areas and found it was very clean. The service had a dedicated Control of Substances Hazardous to Health Regulations (COSHH) cupboard that was securely locked, all chemicals were stored in accordance with legislation and the COSHH folder documented all chemicals including usage and risks in line with Health and Safety Executive guidelines. We observed staff cleaned probes and used disposable covers in line with best practice. All staff were bare below the elbows and demonstrated effective hand washing techniques.

Processes

Score: 3

Staff completed an infection prevention and control (IPC) log that detailed daily requirements for cleaning. This was fully signed and up to date. The manager completed a quarterly hand washing audit and an annual overall IPC audit. The most recent hand washing audits were positive and the last annual audit was fully compliant. As a result of the audit, managers noted a stain on the waiting room carpet, which resulted in the carpet being changed.

Management had oversight of consumables ordering, storage and destruction. We saw there was stock rotation of consumables to ensure the oldest products were used first. We checked 20 consumables and noted they were all in date. Sharps bins were secured and not overly full.

Blood kits were individually wrapped and contained all instruments required for the test. These were ordered centrally and sent back for destruction. All storage and transportation bloods were arranged via a third party.

We did not look at Medicines optimisation during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.