Window to the Womb Reading

On this page

• 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

We found a breach of the legal regulations related to governance, Regulation 17 as some areas of governance were not sufficiently robust to ensure effective oversight of the service. The hand washing sink, was not risk assessed to ensure it was solely used for hand washing. Incident and complaint files did not include follow up information and some policies contained irrelevant information.

The culture at the service was open and honest. Staff enjoyed working at the clinic and were overwhelmingly positive about their immediate leadership team. Staff felt empowered to make suggestions and felt able to contact the service Freedom to Speak Up Guardian if they had an issue or concern. All staff were aware of the services vision.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Feedback from staff and leaders

Score: 3

All staff said there was an open and honest culture at the service, and they were overwhelmingly positive about their experiences of working at the clinic. Staff comments included “I am very happy here”, “It is a great team”, “I love it, couldn’t be happier”, “I’m really enjoying the new role”.

Processes

Score: 3

Whilst the service did not have an individual set of values, the ethos of the Window to the Womb franchise was embedded with staff. The service was focused on being value for money and building trust with the women and families that used the service.

Feedback from staff and leaders

Score: 3

All staff were very complimentary about the registered manager. They advised us they were open to discussions, and they felt they could go to them with any issues or concerns. All staff advised us they were supportive in helping them develop their careers and cared they maintained a work/life balance.

Processes

Score: 3

The registered manager was a radiographer by background. Staff advised us this helped them feel assured they were appropriately trained to support them in their roles and understand any concerns they may have. The manager had been in post for 7 years, during that time they had completed both internal and external managerial courses in order to increase their experience and understanding of managing the clinic.

Feedback from staff and leaders

Score: 3

All staff felt they could go to managers with issues and concerns and described the management team as having an “Open door culture”. All staff knew who the services Freedom to Speak Up Guardian was and stated that any concerns raised were acted on immediately. We saw a corporate Freedom to Speak Up poster in the staff room.

Processes

Score: 3

Monthly team meeting agendas included a section to discuss anonymous concerns and suggestions. The service had a detailed Freedom to Speak Up policy that detailed employee rights and gave details of how to raise a concern as well as escalation if required. In the 12 months prior to inspection, the service did not have any Freedom to Speak Up referrals.

Feedback from staff and leaders

Score: 3

Staff advised us they felt there was equal opportunity for career progression and promotion regardless of background or whether staff had a protected characteristic.

Processes

Score: 3

Staff working at this service were from a diverse background. Managers supported those who had moved to the UK to live and work by ensuring they received support in understanding how to navigate around Reading, how to travel from their accommodation to the clinic and what facilities were available in the local area.

Feedback from staff and leaders

Score: 3

Staff advised us they had regular monthly team meetings. These were organised in order to ensure all staff were able to attend and staff had access to minutes and were kept up to date on actions and changes.

Processes

Score: 2

We found a breach of the legal regulations related to governance, Regulation 17 as there were some areas of the service where governance was not sufficiently robust. For example, the service did not have a clinical sink, and the hand wash area was not risk assessed, incidents and complaints documentation did not include actions and follow up. There was no official translation service, employee files were not fully completed in accordance legal requirements, and policies were not always relevant.

However, the manager had a good understanding of the risks affecting the service. They met with the area manager twice weekly to review performance, there were no formal arrangements for governance meetings with the franchiser, however we saw evidence of ad hoc meetings when required. The manager met quarterly with the providers 2 clinical leads and attended quarterly internal nominated individual meetings with other Window to the Womb franchisees. Governance systems were overseen by the franchiser who completed a full catalogue of audits.

People’s experience

Score: 3

People we spoke with were aware of the service’s 10-year anniversary celebrations.

Feedback from staff and leaders

Score: 3

Staff were positive about the 10-year anniversary celebrations.

Feedback from partners

Score: 3

The local NHS trust advised us they had no issues or concerns regarding this service. The manager organised formalised meetings with the local NHS to improve their relationship and increase engagement.

Processes

Score: 3

The service was celebrating 10 years of Window to the Womb. Staff were involved in numerous events to raise funds for charities associated with the service, including gynaecological cancer and miscarriage charities. This was supported by the franchiser, who were also donating to these charities.

Feedback from staff and leaders

Score: 3

The manager took immediate action to review some of the concerns raised during the assessment. Policies were immediately reviewed and corrected. The manager completed staff health questionnaires, carried out risk assessments for the non-clinical sink in the scan room and registered with interpretation service.

Processes

Score: 2

The service now ensured child sexual exploitation was referenced in their safeguarding policies and evidencing staff completed training in child sexual exploitation. The service had ceased caring for women's’ children during their appointment. However, at the previous inspection we found the service had some policies that were not current, up to date or relevant. We found discrepancies with 2 out of 10 policies reviewed.

Window to the Womb successfully worked in partnership with First Scan. Since the previous inspection, a third partner ‘Plan Your Baby’ had also joined the partnership. Plan Your Baby is a fertility specialist with services including egg freezing. Plans to include Plan Your Baby services on-site was under development.