Womb With A View Grimsby

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 looked for evidence that leadership, management, and governance supported the delivery of safe, high-quality, and person-centred care. We also looked for evidence that leaders maintained appropriate oversight of the service, promoted a positive culture, and supported the ongoing development of the service.

This was the first assessment for this service and well-led has been good.

This meant the service was consistently managed and well-led. Leaders had the skills, knowledge, and experience to operate the service effectively and maintained oversight of quality and safety. There was a positive culture that supported safe care, openness, and a focus on meeting the needs of people using the service.

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.

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.

The service promoted a shared culture centred on high-quality, safe and person-centred care. The registered manager described a clear vision and set of values that emphasised compassion, innovation and continuous improvement. Staff understood the service's aims and contributed to their delivery through a flexible and responsive approach to care. Leaders demonstrated a commitment to developing the service in response to people's needs while maintaining oversight of quality, safety and sustainability.

The service’s vision and values were displayed within the premises and were reflected in day-to-day practice. Staff understood the vision and described how they provided personalised support, and sufficient time during appointments. Staff spoke positively about working for the service and described a collaborative and supportive culture. They told us they felt respected, valued, and able to contribute ideas and suggestions. Staff described open communication with the registered manager and said their views were listened to when discussing service development, operational changes and opportunities for improvement.

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 was led by a registered manager who was responsible for the day-to-day operation of the service. The registered manager demonstrated the skills, knowledge and experience required to manage the service safely and effectively. They had a good understanding of the service, the population it served and the challenges associated with delivering independent healthcare. Leaders were visible and approachable to both patients and staff and clearly described the arrangements in place to maintain safety, quality and a positive experience for people using the service. Staff were supported to develop their skills and take on additional responsibilities where appropriate.

Staff spoke positively about working within the service and described supportive working relationships, effective communication, and a shared commitment to delivering high-quality care. Staff were consulted and involved in service development and their views sought operational changes and improvements were considered. Staff told us they felt respected, valued and listened to and were confident raising concerns, suggestions and ideas for improvement.

The registered manager demonstrated a clear understanding of the risks and challenges facing the service. They identified workforce sustainability, recruitment, infection prevention and control, safeguarding and service capacity as areas requiring ongoing oversight. They used risk assessments, audits, and monitoring processes to identify and mitigate risks and support the safe delivery of care.

The service maintained oversight of staff competence through appraisal processes, professional registration checks and training records. Sonographers also held substantive NHS roles, where they completed mandatory training, continuing professional development and clinical supervision, providing additional assurance that they remained appropriately trained and competent.

The service employed a small number of staff, which limited opportunities for internal independent challenge and oversight. To mitigate this, the registered manager accessed external support through professional networks, training opportunities, regulatory guidance and external review of selected aspects of service delivery.

The service fostered a positive culture where people felt they could speak up, and their voice would be heard.

Staff and leaders acted with openness, honesty and transparency. Staff were encouraged to raise concerns, share ideas and contribute to service improvement. The culture promoted open communication and staff were confident their views would be heard and considered.

Staff described a supportive culture where they felt able to speak openly about concerns without fear of negative consequences. They told us that concerns were taken seriously and that they would be supported and treated fairly if they needed to raise issues. When concerns were raised, leaders responded appropriately and investigated them sensitively and confidentially.

The service maintained a whistleblowing policy that included both internal and external routes for raising concerns. Staff understood their responsibilities to speak up and were aware of escalation routes, including relevant professional bodies and regulators where necessary. Staff told us they felt confident using these processes and believed concerns would be listened to and acted upon appropriately.

The service valued diversity within its workforce and worked towards an inclusive and fair culture by promoting equality and equity for staff.

Leaders told us they would take action to address any disparities in the experiences of staff with protected equality characteristics. The service had policies in place to support equality, diversity and inclusion, including an Equality Impact Assessment policy. Staff had completed relevant training and demonstrated an understanding of how to support people and colleagues with protected characteristics.

Staff described an open and inclusive culture where individuals were valued and respected. They felt confident raising concerns about discrimination, inappropriate behaviour or unfair treatment and were assured these would be addressed appropriately. Staff told us they were treated fairly and would feel able to challenge or report conduct that was inconsistent with the service's values and expected standards of behaviour.

The service had clear responsibilities, roles, systems of accountability and good governance processes. These supported the delivery of good quality, sustainable care, treatment and support. Leaders acted on information about risk, performance and outcomes and shared information securely where appropriate.

The service operated effective governance processes through day-to-day oversight and regular governance meetings. A range of information was collected, monitored and reviewed to support the safe and effective delivery of care. Relevant information was discussed at governance meetings and shared with staff to promote learning and continuous improvement.

Leaders monitored and analysed performance information to identify opportunities for improvement. Where improvements were required, action plans were developed, implemented and monitored. For example, feedback from people using the service was reviewed and used to strengthen the information provided before appointments, including updates to website content, consent documentation and communication processes.

Staff understood their roles and responsibilities and knew how to escalate concerns. Policies, procedures, audits and risk assessments supported oversight of quality, safety and service performance. Policies were regularly reviewed and staff had access to current guidance and operational information.

Risks were identified, assessed and monitored through governance processes, audit activity and risk assessments. Areas reviewed included workforce sustainability, business continuity and service capacity. Risks affecting the operation, sustainability, strategic development or safety of the service were recorded on the risk register and reviewed regularly by the operations director.

Audit activity included infection prevention and control, health and safety, environmental checks and peer review of scan quality. Findings were reviewed and actions taken where improvements were identified. We reviewed governance records and found that risks, issues and actions were discussed, documented and monitored to completion. Information from incidents, referrals, feedback, complaints, audits and training compliance was used to support ongoing oversight and service improvement.

The registered manager received regular supervision and support from the operations director and worked collaboratively with them to maintain oversight of quality, safety and performance.

Effective information governance arrangements supported the secure management of records and personal information. Electronic and paper records were stored securely, and staff understood their responsibilities regarding confidentiality and data protection.

The service also maintained business continuity arrangements, safer recruitment processes and systems to monitor staff training, qualifications and professional registration. Staff had access to the equipment, technology and information required to undertake their roles safely and effectively.

Staff worked in partnership with healthcare providers, community organisations and other services to help ensure care was joined up and responsive to people's needs.

Staff had established working relationships with local NHS services and used referral pathways to support safe and timely onward care. Where concerns requiring further assessment were identified during scans, staff completed referrals, shared relevant information securely and supported people to access appropriate NHS services. Referral processes had been strengthened to ensure referrals were documented appropriately and people were supported throughout the process.

Staff understood arrangements for working with external organisations and healthcare providers. Established referral and escalation pathways with local NHS maternity services supported continuity of care and enabled people to access further assessment when required. Service level arrangements were maintained with external providers where required, including laboratory and waste management services. Staff understood how to work collaboratively with partner organisations to meet people's needs.

Staff worked closely with local NHS maternity services, including Early Pregnancy Assessment Units and other specialist services. They described positive relationships with NHS colleagues and demonstrated an understanding of how partnership working supported continuity of care and positive outcomes for people.

Staff had developed links with a range of community organisations and support services. These included local maternity wellbeing services, baby banks, Women's Aid, miscarriage support organisations, pregnancy and birth preparation services, and community family support groups. Staff signposted people to these services where appropriate to support their wider health and wellbeing needs.

Leaders maintained links with other ultrasound providers and healthcare professionals and described sharing information, discussing developments within the sector and seeking advice when required. These relationships supported learning, service development and the sharing of good practice.

Staff also worked with external providers involved in delivering aspects of care, including independent laboratories. Information was shared securely and only with appropriate consent to support testing, reporting processes and continuity of care.

People using the service were encouraged to provide feedback through online review platforms and direct feedback mechanisms. The registered manager reviewed feedback as part of ongoing service development activities. Feedback was consistently positive and highlighted compassionate care, effective communication and a supportive environment.

Staff understood the importance of collaborative working and information sharing. They knew when information needed to be shared with partner organisations and followed appropriate information governance processes to support continuity of care and joined-up service delivery.

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 demonstrated a commitment to learning and continuous improvement. Staff described an open culture where they felt comfortable sharing ideas, raising suggestions and contributing to service development.

Where opportunities for improvement were identified, staff and leaders worked collaboratively to develop and implement solutions. For example, discussions with the sonographer led to the introduction of a cleaning log for transvaginal ultrasound probes in line with professional guidance. Feedback from people using the service also resulted in improvements to website content, consent documentation and communication processes to help ensure people received clear and consistent information before appointments.

Staff were supported to maintain and develop their skills through ongoing training, professional development and engagement with professional networks. The service maintained links with other ultrasound providers and healthcare professionals to support learning, reflection and the sharing of good practice.

Leaders sought external advice and expertise where appropriate and described plans to develop the service in response to changing demand and the needs of people using the service. Learning from feedback, staff discussions, audits and day-to-day practice was used to inform service development and support continuous improvement.

Learning and improvement activities were proportionate to the size and nature of the service.