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

At our last assessment we rated this key question Requires Improvement. At this assessment the rating is Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. However, there were some areas of the governance process which were not always used effectively to drive improvement within the service.

We found that the service was in breach of regulation for good governance

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.

We scored the service as 3. The evidence showed a good standard. 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.

Leaders had clear organisational vision, underpinned by the franchise’s ethos. At a local level, managers explained their plans to extend the clinic, by expanding their clinical ways of working and were actively monitoring progress.

We observed a culture where managers interacted positively with women and families during our visit. This mirrored what staff told us that leaders were visible, approachable and “easy to contact.”

We scored the service as 2. The evidence showed some shortfalls. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

Some staff told us they had limited opportunities to share views franchise wide, and this reduced their sense of involvement in organisation decision-making.

The service followed a traditional organisational structure with clear responsibilities and a transparent chain of command. One managing director shared responsibility for the clinic, a senior management team, including the registered manager and area manager oversaw operations within other locations including this one together. Staff and managers told us that the area manager was available at short notice.

The service did not have a standardised or structured approach to developing staff into management roles. Managers often recruited internally; with junior scanning assistants progressing into clinic manager roles and clinic manager roles into area manager roles.; however, there was no formal management training programme. Training was delivered on a one-to-one basis and relied on observation and informal learning. This lack of consistency was evident in how staff appraisals were completed.

Registered manager and area managers played a key role in day-to-day operations. They ensured teams were briefed. Monitored clinic managers who were onsite, completed compliance checks, checked rota, and responded to tasks set by leaders.

There had been no staff related complaints in the past 12months, and no staff had taken sickness absence due to workplace injury.

We scored the service a 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service maintained an open culture that encouraged staff to raise concerns without fear. The service had a Freedom to Speak Up (FTSU) policy and guardian positioned, both of which were accessible to all staff. The policy clearly outlined how staff could raise concerns and what they could expect in response, promoting transparency and support.

The service also had a whistleblowing policy that enabled staff to raise concerns confidentially with any members of the management team. Managers we spoke with understood their responsibilities when handling whistleblowing concerns, and staff said they felt confident the senior leadership team would respond appropriately.

The team was small, including managers, and because of that, we were able to observe the close working relationships within a culture that valued everyone’s contributions. Staff told us that issues were rare and that they worked together effectively to resolves problems when they arose. The recent staff survey mirrored this.

We scored the service a 3. The evidence showed a good standard. 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 compliant with a wide range of mandatory training modules, and these modules included Equality, Diversity and Inclusion (EDI) training and there was a dedicated, up to date policy created by the franchise. We spoke to staff and they 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.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We identified a significant number of issues in governance documentation concerning various areas of the services. The service did not always manage risk issues or performance effectively.

Although a risk register was available, the systems and processes for identifying and monitoring risk were not consistently used. We reviewed the services risk register dated January 2025. For example, their risk register identified 2 highest‑priority risks: machine failure and ambulance non-attendance in an emergency. However, they had not documented key governance information for either risk. There were no recorded dates for when the risks were identified, no evidence of review dates and no indication of current status of each risk, such as whether they were active, ongoing or resolved. It was unclear whether these higher rated risks and the rest of the risks documented were regularly reviewed, whether mitigating actions had been tested or whether risk scores remained appropriate. As a result, the service could not demonstrate clear oversight of risks or evidence as to how these were being mitigated in a timely way.

The service considered 6 risks in total for their risk register; however known risks were not formally recorded. These included risks related to the ongoing issue of women attending appointments without staff being able to identify individual or additional needs in advance. While staff were aware of these risks and described actions taken to manage them, there was no clear, accurate or up-to-date record to support this.

Policies did not always support effective governance. For example, the COSHH policy did not clearly specify review timescales, limiting assurance that risks from hazardous substances were reviewed regularly. The IPC policy required daily cleaning of clinical and non-clinical areas; however, this was not reflected in what we saw as part of the assessment. Although a Patient Support Policy outlined the use of professional translation services, staff were unclear how to access these and relied on informal methods. Managers were also not fully aware of the associated risks prior to the assessment.

The service had an audit programme which included monthly local audits, annual audits and peer reviews; however, they weren't always utilised effectively. For instance, the services audits had not been effective in identifying the IPC and COSHH concerns identified during the assessment, meaning that action could not always be taken to drive improvement. Along with that, the did not audit women’s records, including whether information was gained as to women’s additional needs. This limited oversight and the ability to drive improvement in this area and to improve patient experience.

An emergency policy and contingency plan was established by the service to cover scenarios such as staff absence, equipment failure and utility disruption. Annual compliance audits were conducted by the franchise operations manager, and action plans were developed in response to findings. The registered manager completed monthly clinic visits and shared performance data against key indicators with staff during team meetings.

We scored the service as 3. The evidence showed a good standard. 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 engaged with regional networks to better understand local community needs and the franchiser’s ambitions.

The service worked with a local photographer to provide the images displayed in the clinic. It also partnered with two fertility companies that use them for scans and blood tests. Women's blood samples were sent to laboratories both of which the service maintained regular contact with to ensure it delivered the highest standard of care.

The service managed its social media platforms centrally and used them to share information. Staff told us this was an effective way to engage with the local community and promote the service.

The franchise ran internal competitors between clinics to see who could sell the most teddy bears. However, managers told us they did not apply pressure to staff and ensured products were offered appropriately rather than promoted aggressively.

We scored the service as 3. The evidence showed a good standard. 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 service used electronic patient feedback as a learning tool to improve women outcomes. Leaders and managers contacted women who rated their experience as four stars or below to understand concerns and identify opportunities for improvement. Managers regularly reviewed patient feedback in meetings to monitor themes and trends and acted where needed. This approach supported consistent outcomes and ensured care met both clinical standards and people’s expectations.

Since the previous CQC inspection, the service improved how women access and receive scan images and information. Previously, women were required to download scans manually. In early October 2025, the service introduced a digital platform. This online application allowed women to securely access scan images, reports, and key information in one place. It also supports improved communication between the service and women by providing timely updates and digital sharing of information.

Staff told us the app improved the overall patient experience by making information easier to access and reducing delays. Leaders also explained that partner organisations, including fertility providers, would be integrated with platform over time. This would allow for improved information sharing, stronger partnerships, more coordinated care across services.