Window To The Womb

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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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. However, not all staff were familiar with the service strategy and priorities.

Staff could explain how they were working to deliver high quality care.

We observed staff interacting positively and respectfully with each other, women and their loved ones during the assessment. Staff reported a positive and supportive culture.

Staff prioritised creating a welcoming, nice and warm environment for women and their families.

Leaders completed an annual audit and quality checks of various standards such as environment and staffing to support continuous compliance, learning and quality assurance.

Leaders knew and understood the provider’s vision, strategy and values and how they were applied in the work of their team. At a local level, managers explained the franchise’s plans to extend the service provision and priorities were linked to client satisfaction, sales targets, key performance indicators (KPIs) and engagement. Leaders told us the strategy and priorities were set by the franchise. However, not all staff could articulate the service strategy or priorities. It was unclear if leaders had successfully communicated the provider’s plan to the frontline staff in this service.

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.

Leaders had the skills, knowledge and experience to perform their roles. Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. However, they did not always have oversight or awareness of the risks within the service such as the infection prevention and control risk identified during the assessment.

The service leadership team consisted of a registered manager, area managers and a clinic manager. The clinic manager managed the service on a daily basis. There were clear lines of reporting from the service leadership to the franchise leadership team. The registered manager and area managers reported to the service director and they were all responsible for 12 clinics under the franchise.

We observed, and staff told us leaders were visible in the service and approachable for staff, women and their loved ones.

The service offered an informal in-house shadowing and leadership development opportunities, which were available for all staff. However, this was not standardised, and there was no formal management training programme for staff.

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

The service had an open culture where women and their families and staff could raise concerns without fear. Staff at all levels we spoke with reported feeling comfortable speaking up. Staff were encouraged to raise concerns and promote the value of doing so.

Women and their loved ones had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Women and staff could meet with the leadership team to give feedback.

The service had a freedom to speak up (FTSU) policy and guardian in place, and staff knew how to access them for support. The FTSU policy detailed how staff could raise concerns and what they could expect in response, promoting transparency and support.

Managers and staff had access to the feedback from women, and their loved ones and staff used it to make improvements.

Women and the public were involved in decision-making about changes to the service through the service's social media platforms.

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 able to apply to work flexibly and we observed some staff had flexible working agreements which took account of their personal circumstances, such as caring responsibilities and health issues.

Staff were compliant with the Equality, Diversity and Inclusion (EDI) training and there was a dedicated, up to date policy created by the franchise. Staff we spoke to fully understood their responsibilities under this policy.

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

The service ensured that its staff were diverse in their makeup and representative of the women's group they served.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

There was a clear framework of what must be discussed at team and governance meetings to ensure that essential information, such as learning from accidents and complaints, was shared and discussed.

The service had an audit programme, which included monthly, local audits, annual audits, and staff peer audits. Staff undertook or participated in local clinical audits and peer reviews. The audits were sufficient to provide assurance, and staff acted on the results when needed.

Staff understood the arrangements for working with other clinics within the franchise, and external organisations, to meet the needs of the women.

Staff maintained and had access to risk assessments and a risk register. At the time of the assessment, the service had 6 open risks. These included issues such as the availability of sonographers, scan machine failures or fault sand ambulance failing to arrive at the clinic during an emergency. The risk register contained key information such as description of risk, risk owner and current rating. However, the risk register did not include when the risks were added to the risk register.

The service had plans for emergencies, which covered scenarios such as adverse weather, staff absence, utility disruption or a flu outbreak.

Staff had access to the equipment and information technology needed to do their work.

Information governance systems included the confidentiality of women's records. Managers had access to information to support them with their management role. This included information on the performance of the service and staffing. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

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 and area manager engaged with their regional networks to understand the local communities serviced, their needs and the franchiser’s ambitions.

The service had a strong online presence and staff actively engaged with women, their loved ones and public via their social media platforms and used feedback to drive improvement to the service. Staff told us their social media handles and online review platform were effective in helping them to engage with women, the local community and promote the service.

Staff told us they engaged well with each other and had regular team outings such as team dinners during the festive period to improve team engagement, working and staff wellbeing.

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 promoted continuous learning and improvement. Managers encouraged creative ways of delivering equality of experience, outcomes and quality of life for women who accessed the service. For example, the service used positive and negative feedback received as a learning opportunity to improve service delivery and outcomes for women.

Managers contacted those who had made a complaint, rated their care as 3 stars or less, to understand their concerns and how the service could make improvements in the future. Staff discussed feedback received at team and governance meetings to monitor themes and trends and take appropriate action to drive improvement.

Staff were committed to improving service delivery by learning from when things went well or wrong, promoting training and their development. There was evidence of continuous professional development amongst staff. Staff were given the time and support for reflection and development during their team meetings, which has led to improvement in care and service delivery.