Window To The Womb

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

This means we looked for evidence that people were protected from abuse and avoidable harm and safety was a priority for everyone. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm. Clinic areas were clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to women and themselves well. Staff understood how to protect women from abuse and the service worked well with other agencies to do so. The service managed patient safety incidents well. However, staff did not always adhere to infection prevention and control standards, ensure consumable items were in date, or ensure the environment was free from hazards. Staff did not consistently provide safety netting advice to women. The service was in breaches of regulation in relation to safe environment and risk assessments.

We have not awarded this service a score for Safe.

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

The service had a positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported accidents. Lessons were learnt to continually identify and embed good practice. However, we were not assured staff consistently reported safety events.

Staff we spoke to knew what incidents and accidents to report and how to report them. Data submitted showed there had been 0 incidents reported within the past 12 months. At the last inspection, the service did not have an incident policy, and we were not assured that staff recognised incidents and reported them appropriately. At this assessment, we noted that the service now had an incident policy in place, and staff confirmed they had not had any clinical incidents such as ectopic pregnancies in the last 12 months. However, we noted a non-clinical incident from a client complaint, which related to faulty equipment and had not been reported by staff in their incident logbook. Staff told us that this would have been addressed promptly by the clinic manager, but they would not be expected to report this as an incident. This was not in line with their policy. The incident logbook showed the last 2 reported incidents by staff occurred 5 to 6 years ago for ectopic pregnancies. This raised a concern that staff did not always report non-clinical incidents in the service. We saw evidence of accidents reported within the past 18 months, including the actions taken.

Staff understood the duty of candour and had access to an up to date duty of candour policy. They were open and transparent and gave clients a full explanation if and when things went wrong. Staff also received specific training on how to deliver bad news to women and their loved ones, and they were encouraged to do refresher training where required.

Staff had regular monthly meetings and discussed any safety incidents and accidents that occurred in the service or other sister locations within the franchise to drive improvement in the service. The service had a process to debrief staff following a severe accident or serious incident. There was evidence that changes had been made as a result of feedback and learning from incidents. For example, the October 2025 clinical governance meeting included discussion and learning on a missed abnormality incident that occurred at another clinic, which had prompted an updated training package for sonographers. The sonographer also attended regular virtual meetings with the general manager and colleagues from other clinics to discuss learning from incidents that had occurred across the region.

The service policies, guidelines and procedures were up to date and aligned with national guidance and some of the policies were displayed in the clinic to promote a safe learning culture. This included standards from the Royal College and Society of Radiographers, the foetal abnormality screening programme, and the British Medical Ultrasound Society.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service worked with people, charities, local hospitals and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care for women, this include advising women to still attend their NHS routine scans as part of their maternity pathway.

Staff worked with local authorities, general practitioners (GP), hospitals and social services to manage women safety effectively. They signposted women to the contact details of local NHS hospitals, fetal medicine unit’s or early pregnancy unit’s if women had any concerns during or prior to their appointment at the clinic and needed advice or if an abnormality was found during the scan. Staff signposted women who experienced a miscarriage to external partners, such as The Miscarriage Association who provided support to those experiencing pregnancy loss. Where women were unhappy with their scans due to factors such as poor image quality, the service would offer a rescan at no additional cost.

The service’s self referral and booking processes ensured that all essential information about the client was received to determine if the woman’s needs could be safely met. The clinic managers monitored the electronic booking system daily and the service offered flexible appointments for women, which can be booked online 24/7 or by contacting the customer service telephone line. The service was open 5 days a week including afternoons, evenings and weekends. The service had a system in place to follow up with women who did not attend their appointment.

All women were required to complete a pre-scan questionnaire during booking and arrival to the clinic. This covered the women’s obstetric history, medical history and a signed declaration confirming NHS care and consent to share medical information if required. We observed staff checking with women’s understanding of their booked scan, its limitations and what will happen during the procedure prior to commencing the scan. This was in line with best practice.

The service had clear guidelines and protocols for managing clinical risk and escalating abnormal findings, including ectopic pregnancy diagnosis and obstetric emergencies, to ensure the safety of women and unborn babies. This included policies for Fetal ultrasound and Responding to a missed or incorrect diagnosis. The fetal ultrasound policy included the referral pathways, process for communicating findings and management of unexpected findings. As part of the service’s emergency policy, staff were required to complete an emergency referral form and refer to these details when contacting the emergency services. Staff were required to provide a copy of the referral form to the paramedics on arrival to ensure a smooth handover to emergency services, and staff were required to record such an incident in the clinic’s incident log.

The service had a policy that outlined actions to be taken in the case of a missed or incorrect diagnosis. The policy outlined the investigation process and contact timeframes.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The service had an up-to-date safeguarding of adults and young people’s policy, and the policies were on display in the reception areas. The policy was updated annually and included signposting women to other agencies where required. Clients that were aged between 16 to 18 years old were required to attend the clinic with an adult and asked for identification details, which was in line with best practice and their policies.

Staff were trained in female genital mutilation and safeguarding adults and children, knew how to make a safeguarding alert and actioned this when appropriate. Training data showed that all staff had received safeguarding training appropriate for their role. Managers and sonographers were level 3 trained, while the scan assistants were level 2 trained for safeguarding. Staff had also received training on the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) and Oliver McGowan Mandatory Training on Learning Disability and Autism. Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.

Staff understood their responsibilities and adhered to safeguarding policies and procedures, which include seeking advice from managers on safeguarding concerns, notifying the local authorities and reporting safeguarding concerns which required further investigation. Staff could give examples of how to protect women and colleagues from abuse, harassment and discrimination, including those with protected characteristics under the Equality Act. The clinic had not needed to raise any safeguarding referrals in the 12 months prior to assessment. However, staff gave examples of safeguarding referrals and learning that had occurred in other clinics. All safeguarding referrals were logged and reviewed by the clinic manager and registered manager to ensure appropriate follow-up.

The service displayed information regarding safeguarding from abuse in the toilet, enabling women to discreetly access essential information and support services when needed.

Staff had a process in place to review and monitor staff recruitment records to ensure the safety of women and the public. We reviewed staff recruitment records whilst on site, and noted all records were in date. The service carried out monthly audits of recruitment checks, to ensure staff Disclosure and Barring Service (DBS) certificates were renewed where needed for the registered manager, clinic manager, sonographers and scan assistants.

Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. However, staff did not consistently work well with people to understand and manage risks relating to bleeding during pregnancy. There were gaps in the documentation of some women's scan results, and staff did not consistently provide safety netting advice to women.

Staff carried out a comprehensive risk assessment for women from booking to the ultrasound scan appointment, which included obstetric and gynecology history and risks associated with pre-existing health conditions. However, the service did not consistently work with women and their loved ones to understand and manage obstetric risks associated with bleeding during pregnancy. Staff did not consistently provide or document safety netting advice for women who presented with or expressed concerns about bleeding. We observed 4 early and gender scans and reviewed 11 women's scan reports. Staff generally completed risk assessments. However, safety-netting advice was not documented in the records of women who attended for reassurance scans due to bleeding. In addition, staff did not consistently document whether haemorrhage (bleeding) was observed during the scan. In 2 of the records reviewed, there was no record of whether bleeding was present and no measurement of bleeding was documented. One woman’s record noted that mild bleeding was observed; however, there was no documentation that clear verbal or written safety-netting advice about symptoms requiring urgent medical attention had been provided. This was not in line with National Institute for Health and Care Excellence (NICE) guidelines on abortion care, ectopic pregnancy and miscarriage (NG126 and NG3) and Royal College of Obstetricians and Gynaecologists (RCOG) guidance on early pregnancy care. It is good clinical practice for staff to provide clear verbal and written information and safety-netting advice for women who present with early pregnancy bleeding about what symptoms to monitor and when to seek urgent medical advice, including contacting emergency services or their GP if bleeding becomes heavier or if they experience pain.

The service had effective systems to identify and respond to clinical risks, including suspected ectopic pregnancy and miscarriage. Sonographers followed clear guidance where unexpected findings were identified. The service had set limits on the number and frequency of scans to support women’s safety, advising no more than one scan within two weeks. Staff made it clear that private scans did not form part of NHS maternity pathways and did not replace screening offered through the NHS Fetal Anomaly Screening Programme (FASP). Women were discouraged from booking private scans during the 18 to21-week period to avoid impacting attendance at the NHS 20-week fetal anomaly scan.

The service had various protocols in place for emergencies and a clinic manager was always present on every shift to call an ambulance for various conditions, such as ectopic pregnancies. The service also had a clinic contingency action plan and an emergency action plan, which covered various situations such as equipment failure, utility disruption and staff absence. In such an event, staff were required to follow the contingency plan.

Staff communicated with women so that they understood their scan results including finding effective ways to communicate with those with communication difficulties.

Staff enabled women to give feedback on the service they received via online surveys and face to face feedback.

The service did not always detect and control potential risks in the care environment. We found some out of date consumable items in the first aid box. However, staff ensured facilities and technology supported the delivery of safe care.

We found some out-of-date consumable items in the first aid box located in the scanning room. These included 11 lubricating jelly sachets that had expired in 2009 and were not stored in their original packaging. We also found four saline sachets that had expired in November 2024 and bandages that had expired in February 2022. This meant the first aid kit may not have been readily available and fully fit for purpose if required during an emergency or accident, as expired consumables may not be safe or effective to use. This was not in line with the Health and Safety Executive First Aid at Work Regulations 1981 which required employers to ensure first aid equipment were adequately maintained, suitably stocked and in date. There was also a risk that expired items could have been used in error, which may expose women to the risk of harm or infection. We escalated these concerns to staff during the assessment. Staff disposed of the expired consumables and replaced them while we were on site. Staff also advised that there was another first aid kit located in the staff kitchen. We checked this kit and found that all consumable items were within their expiry dates.

We observed 4 electric sockets that were loose and not securely fixed to the wall. Staff had not identified these as potential electrical or safety risks. This was not in line with the Electricity at Work Regulations 1989, which required electrical systems to be constructed and maintained to prevent danger. The Health and Safety Executive Workplace Regulations 1992 requires employers to ensure workplaces are maintained in a safe condition, which are free from hazards such as unsafe electrical installations or trip hazards. In the scan room, we also observed an electrical cable on the floor that was not secured to the wall and ran underneath the clinical sink. This created a potential trip hazard and increased the risk of injury or electric shock for women, visitors and particularly staff who had to step over the cable in order to access the sink for handwashing. We escalated these concerns to the registered manager during the assessment. The registered manager informed us that the service was undergoing refurbishment. They advised that refurbishment of the staff kitchen had recently been completed and that the scan room was scheduled to be refurbished next.

Although regular environmental and health and safety risk assessments were in place, the above issues, including the electric sockets, had not been identified by staff and leaders as safety risks. However, staff completed all risk assessments including the control of substances hazardous to health (COSHH).

Due to the limited space within the clinic, there was no dedicated quiet room for women and their loved ones to use for sensitive situations, for example, if the sonographer had to deliver bad news and if the women were distressed. Staff recognised the need for people’s privacy and managed this by allowing women and their families to remain in the ultrasound scan room for as long as they needed. Staff would apologise to other women accordingly for potential delays in being seen by the sonographer. Staff told us most women prefer not to stay after receiving bad news, and they have not had a complaint in relation to this.

However, the design of the environment followed national guidance, and the clinic was clean, well-furnished, suitable and fit for purpose. Staff ensured the safe disposal of clinical waste and segregated clinical and general waste.

All equipment was labelled with up-to-date portable appliance testing and service maintenance checks. The scanning equipment, including probes were serviced and calibrated in line with the manufacturer's guidance. The clinic manager oversaw the timely servicing and maintenance of ultrasound equipment.

Fire extinguishers were accessible, serviced, and correctly stored.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision, and development. Multidisciplinary staff worked together well to provide safe care that met women’s individual needs.

The number of staff in the clinic matched the expected staffing levels for all clinic shifts and the services being provided. At the time of the assessment, the service had no staff vacancies. In the last 12 months, the service had low turnover and low sickness absence rates.

When necessary, managers redeployed sonographers from other clinics within the franchise to cover annual or sick leaves to maintain safe staffing levels. When staff from other clinics were used, those staff received an induction and were familiar with the clinic.

According to current UK legislation, there is no current legal requirement for the title "sonographer" to be protected. However, the Society of Radiographers (SoR) states that for “safety, accuracy, and medical reliability, baby scans should only be performed by qualified sonographers, radiographers, midwives, or doctors.” All sonographers within the franchise, including the clinic’s sonographer, were registered with the Health and Care Professions Council (HCPC) and were also members of the Society of Radiographers (SoR). The sonographer was regularly assessed by scan reviews and assessments by a senior sonographer as part of their competency checks and continuous professional development. Peer review is strongly advocated by the Royal College of Radiologists and the Society and College of Radiographers. We saw evidence that the service had completed regular peer review audits over the previous 12 months across a range of scans. These audits identified areas of good practice, areas for improvement, and associated actions.

Managers supported staff to develop through yearly, constructive appraisals of their work to deliver safe care. At the time of the assessment, 100% of staff had completed their annual appraisal.

Staff had received and were up to date with the appropriate mandatory training. The training was appropriate for the client group using the service. Training topics include Fire safety, adult safeguarding, safeguarding children, equality and diversity, health and safety at work, first aid, Mental Capacity Act, Oliver MCGowan, Dementia, lone person protocol and information governance.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Although clinical areas were generally clean, well maintained and had the necessary furnishings, we observed dust inside some clinical drawers where masks and gloves were stored. This meant personal protective equipment (PPE) was not always stored appropriately, and staff did not always adhere to infection control principles.

We observed that non-sterile gloves and face masks had been removed from their original boxes and stored in a dusty clinic drawer. This did not support good infection prevention and control practices. We escalated our concerns to senior leaders during the assessment. Staff immediately disposed of the affected gloves and masks and replaced them with new items, which were stored appropriately in their original boxes.

Staff generally followed good hand hygiene practices. However, we observed one occasion where a member of staff did not perform hand hygiene between completing a scan and undertaking documentation. This posed a potential risk of cross-contamination as the member later interacted with a client following their documentation. The space around the clinical sink in the scan room was limited, which may have affected ease of access; however, alcohol hand sanitiser was available in the room and throughout the service. The December 2025 hand hygiene audit showed 100% compliance.

All staff, including the clinic manager, area manager and registered manager, had not received formal training on infection prevention and control (IPC). Staff discussed their IPC policy during their staff meeting twice a year, which was in line with their policy. However, the senior staff that carried out hand hygiene audits, IPC training and chaired the staff meeting were the IPC policy was discussed had not completed IPC training or train the trainer to be able to identify and challenge poor practice to drive improvement. This was not in line with NICE Quality Standard QS61: Infection prevention and control which expects that healthcare staff are trained and competent in infection prevention practices, including hand hygiene and use of PPE. This was also not in line with the Health and Social Care Act 2008 Code of Practice on the Prevention and Control of Infections, which requires providers to ensure staff receive appropriate infection prevention and control training. This was a concern as staff and managers had not identified the IPC risks noted during our assessment such as the inappropriate storage of face masks and gloves. This highlighted staff’s limited knowledge of infection prevention and control best practices.

We raised our concerns to leaders and we were told an IPC e-learning package will be commissioned and rolled out to all staff and managers. Post assessment, we received evidence which showed that the training had been commissioned and all staff including the registered manager had completed the IPC training as of 25 February 2026.

However, there was some evidence of good practice. Staff adhered to bare below the elbow and ultrasound probes were cleaned with sanitising wipes after each scan. Cleaning records were up to date and demonstrated that the clinic was cleaned regularly. Staff carried out deep cleaning of the scan room at the end of the clinic’s opening hours.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.