Window To The Womb

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• 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 assessment focused on 1 quality statement across well led: governance, management and sustainability

At our last assessment we rated this key question good. At this assessment we looked at 1 quality statement and the rating has remained good.

At our last assessment the service was in breach of regulations for good governance. At this assessment, the service had not met compliance with this regulation and remained in breach of regulation of 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 did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Although the service had systems of governance which supported staff to work safely, risk management and oversight by leaders remained inconsistent. This remained a risk to patients because identified concerns were not always effectively monitored, escalated or acted upon, increasing the potential for risks to go unrecognised or unmanaged and impacting the quality and safety of care provided.

During our previous assessment we found that, although a risk register was available, the systems and processes for identifying and monitoring risk were not consistently used. Leaders were confident they had addressed these shortfalls by updating the risk register for the clinic. However, during this assessment we spoke with staff and managers who could not tell us where the risk register was kept and could not name the risks on it. As staff were unable to locate the risk register in the registered managers absence, the inspection team were unable to review this document on the day of assessment. This meant the service could not demonstrate that risks were being consistently monitored or that staff had the information they needed to manage risks day to day.

Key policies were accessible, up to date and showed evidence of senior oversight to ensure accuracy, consistency and alignment with national standards.

The service monitored quality and safety through clinical audits, and records showed these were completed in line with the audit schedule. Staff told us the introduction of the new prebooking system would also enable the service to audit peoples additional needs.

Leaders had taken action to strengthen governance following the previous assessment. Policies, including COSHH and Infection control and prevention policies had been reviewed and updated to align with national guidance. Infection Prevention Control (IPC) governance had improved since the last assessment with the service introducing new training.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.