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

At our last assessment we rated this key question Requires improvement. At this assessment the rating is now Good. This meant people were safe and protected from avoidable harm.

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.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. Staff and leaders listened to concerns. Lessons were learnt to continually identify and embed good practice.

Staff facilitated a positive learning culture in line with the provider’s national policies and procedures. The service managed patient safety incidents effectively and had a clear incident reporting policy. This policy outlined how to report issues, the timescales for investigation, and how incidents were assessed according to severity.

In the past year, the service had reported 3 patient safety incidents. These all related to suspected ectopic pregnancies. An ectopic pregnancy occurs when a fertilised egg implants and grows outside the main cavity of the uterus (womb), most commonly in a fallopian tube. Because the egg cannot survive there, it is not a viable pregnancy and requires urgent medical treatment to protect the person’s health. We saw that when an ectopic pregnancy was suspected, staff acted in line with policy. Staff told us this always happened.

We saw that all incidents were reviewed by a clinic manager, formally documented and the learning from these incidents was shared with other external franchise locations. We also saw that staff were debriefed and received support after each incident. The service had not experienced any never events or serious incidents in the past year.

Staff told us they were able to report incidents and risks with confidence, knowing that managers would respond. They also said they felt confident raising concerns and reporting incidents, in line with their policy. We saw when staff required additional support or training following an incident, this was arranged.

The service had an in-date duty of candour. Staff demonstrated a clear understanding of the duty of candour, showing openness and honesty when things went wrong.

Service policies and procedures were up to date and aligned with national guidance. This included standards from the Royal College and Society of Radiographers, the foetal abnormality screening programme, and the British Medical Ultrasound Society.

We scored the service a 3. The evidence showed a good standard. 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’s electronic booking system was monitored daily, offering people the flexibility to book appointments online via a 24/7 platform or by contacting the clinic directly with customer service support available. The service was open 4 days a week including some evenings and all weekend. The booking system issued automatic appointment reminders and allowed short notice rebooking. We saw evidence that managers followed up with women who did not attend appointments.

Women completed a pre-scan questionnaire on arrival to the clinic, which included pregnancy history and a signed declaration confirming NHS care and consent to share medical information if required. There were clear referral pathways with local NHS providers if foetal abnormalities were suspected. When required, staff contacted the relevant NHS units directly and arranged appointments on the persons behalf. Relatives we spoke with, reported good communication between the clinic and NHS maternity teams regarding scan results, referrals and information sharing.

Staff demonstrated clear understanding of emergency protocols and acted according to their policies when required.

We observed sonographers checking women’s understanding of their referral prior to scanning and explaining when reports would be sent to the referrers.

Sonographers followed defined guidance when unexpected findings were identified during scans, explaining results to women and families and making sure scan assistants documented reports accurately

We observed phlebotomists carrying out blood sampling and saw evidence they had completed the required training and development to undertake this. There was a Phlebotomy and Blood Sample Standard Operating Procedure available, clearly outlining the protocol for venepuncture conducted by trained phlebotomists at Window to the Womb clinics.

However, we identified that people with additional needs, including communication requirements, were not consistently being flagged either before or after booking through the initial online prebooking questionnaire. Staff told us they relied on people informing them on their own accord by telephoning or making them aware at the time of their appointment. This concern was raised with managers during the high-level feedback, and they confirmed it had been escalated to the franchise owner to be incorporated into the booking system.

We scored the service a 3. The evidence showed a good standard. The service worked with people and partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

All staff had up to date safeguarding training. Staff were assigned safeguarding training appropriate to their roles and were able to clearly identify their individual responsibility as well as name the safeguarding lead when asked. The safeguarding lead in this instance, was the registered manager of the clinic.

The clinic had not needed to raise any safeguarding referrals in the 12 months prior to assessment. However, staff told us that if they did need to, they understood the process. Staff we spoke with could give examples of how to protect women from harassment and discrimination, including those with protected characteristics under the Equality Act. The service displayed information regarding safeguarding from abuse in the toilet, enabling women to discreetly access essential information and support services.

The service had updated its service user age bands in 2024 to include children and young people aged 13-17 years of age. However, leaders told us that although this change reflected future plans, the service was not currently accepting or providing care to patients under the age of 18 at the time of our assessment. Women were required to verify date of birth when booking online. Staff also verified age with identification at each appointment. Staff reported they would be rebooking a scan if a woman did not have valid ID, and they had done this in the past.

We saw evidence that staff had completed both adult and child safeguarding in line with their clinical roles. Managers and sonographers were level 3 trained for safeguarding the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

The service ensured that sonographers completed continuous professional development where required with the sonographer clinical lead for the franchise. Sonographers also undertook peer review of completed scans to identify areas of improvement. Peer review is strongly advocated by the Royal College of Radiologists and the Society and College of Radiographers.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service had a clear emergency policy that set out the actions staff must take in emergency situations, including contacting an ambulance service for obstetric emergencies and suspected ectopic pregnancies. Staff received appropriate training, including bi-annually training completed during team meetings to help all staff recognise signs of patient deterioration.

Staff understood their responsibility to document scan type and frequency. Staff told us they advised women that they should not undergo more than 1 scan every 2 weeks and were discouraged from attending the scans during the 18-21 weeks period to avoid interference with the NHS 20 weeks anomaly scan.

Staff had access to a first aid box and items within were in date. We saw evidence of up-to-date risk assessments for fire safety and health and safety to identify and mitigate environmental risks. These clearly identified risks, control measures and named staff responsible for monitoring. The service also had policies and procedures such as an emergency action plan and clinic contingency action plan.

We also saw evidence monthly recorded fire checks and fire evacuation training had been carried out, enabling the franchise to monitor staff responses during evacuation procedures.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The design of the environment followed national guidance, and facilities, including the one bathroom included were accessible to patients and visitors with physical disabilities. The entrance to the service had slope to support wheelchair access and staff said they would support those needing help through the entryway as there was a small height difference at the doorstep from the pavement. The reception area was secure; with controlled door access and CCTV coverage, and staff maintained a clear line of sight at all times. In the scanning room, a clean, adjustable surgical bed that met recommended standards was available and a clean secure, dedicated quiet room was provided for sensitive conversations.

Fire extinguishers were accessible, serviced, and correctly stored. There was evidence that staff reported faults and low stock levels to ensure these were replenished.

Staff ensured the safe disposal of clinical waste according to guidance. Clinical waste was disposed of safely, in secure bins. Collection was provided under a contract with third party provider, and the waste policy was current and applicable to the clinic. All equipment was labelled with up-to-date portable appliance testing and scanning equipment and including probes were services and calibrated in line manufacturer guidance. Managers oversaw the timely servicing and maintenance of ultrasound equipment.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Leaders monitored mandatory training compliance to ensure this was completed and reminded staff when updates were required. All staff had completed training nationally recognised and mandated training in supporting women with learning disabilities and autism. Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the patient group using the service and included training regarding ectopic pregnancy, miscarriage awareness, and Female Genital Mutilation (FGM).

We saw that staffing levels were appropriate to the service being provided with no vacancies. During our onsite assessment, the clinic was staffed by a clinic manager, scanning assistant, and a sonographer. Leaders worked together to plan and maintain safe staffing levels dependant on service demand. Staff told us that staffing cover to support annual leave was provided through the relocation of staff from other clinics within the franchise.

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.”

At the time of our visit, the clinic’s sonographer was registered with the Health and Care Professions Council (HCPC) and a member of the British Medical Ultrasound Society.

The job responsibilities of the scan assistants was to manage enquiries and bookings, supporting sonographers during scans and printing scan images. Staff told us that a scan assistant always acted as a chaperone during scans and that all staff were trained to act as chaperones.

Sonographer training included a combination face to face and eLearning. New sonographers completed a structured induction programme, which included shadowing a clinical lead sonographer from the franchise.

The service followed recruitment practices to ensure staff were suitably experiences and competent. All staff files reviewed were mostly complete and included employment checks, references, induction records and initial competency assessments. Managers told us they were awaiting one staff members DBS record. Leaders told us this staff member was never left alone with women and appropriate supervision was always maintained. This was mirrored in their DBS policy. The managers confirmed that the outstanding DBS was actively being chased and would be completed in line with safer recruitment guidance.

The service did not use bank or agency staff; all staff were substantively employed and managed directly by the franchise. Staff told us shifts were safely staffed with adequate breaks. Some staff were employed on 0 hours contracts and they told us they had no concerns regarding this.

However, while leaders, told us that all eligible staff received annual appraisals, the examples we reviewed were brief and lacked sufficient details. Managers told us there was no standardised training or guidance to support them in delivering effective appraisals. This feedback was communicated to the managers during the onsite visit. They reported that they would raise the matter with the franchise leaders for review.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Staff completed daily cleaning checks, with signed and dated records which we observed. However, during the assessment, we observed areas which were visibly unclean throughout the clinic. This was most visible in areas of the scanning room, the toilet and the designated staff kitchen. We saw that the floors of the scanning room, the bathroom and front-of-house area were visibly dirty. We also saw that a sharps bin was not stored and used safely in line Department of Health and Social care (DHSC) health technical memorandum (HTM) 07/01 in relation to the safe management and disposal of healthcare waste.

The service had a dedicated Control of Substances Hazardous to Health (COSHH) cupboard which was securely locked. Staff completed mandatory COSHH training. However, the service policies did not specify timescales for reviewing COSHH checks. We saw COSHH checks had not been completed since February 2025, and a chemical item not stored in line with legislation.

We highlighted these concerns to leaders who acted quickly and responded to our concerns.

However, there was some evidence of good practice. We reviewed data of hand hygiene audits within the past 12 months which showed 100% compliance with hand hygiene standards amongst all staff employed at the service. We saw that staff did have access to suitable handwashing facilities within immediate clinical areas.

Staff adhered to bare below the elbow protocols and had access to PPE including gloves and aprons in a range of sizes in accordance with Health and Safety Executive requirements. Ultrasound probes were cleaned with sanitising wipes after each scan, and the ultrasound machine was cleaned at the end of each day. Women using the service reported no issues with equipment and described the premises as “very clean and tidy” during their visit.

The service did not store, supply or administer any medicines. The score for this quality statement is based on the previous rating for Safe.