Window to the Womb

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Our overall rating of effective at Window to the Womb Chester le Street is good. At our last inspection we did not rate effective.

People’s individual needs were assessed. Care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. Diagnostic procedures were based on latest evidence and good practice guidance. Leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work. Managers monitored performance and ensured staff were competent. They identified service improvement opportunities through effective audits. Staff worked collaboratively, supported people in making informed choices, and provided access to relevant information. Staff made sure patients understood their care and treatment to enable them to give informed consent for treatment in accordance with guidelines. Staff proactively supported people to live healthier lives.

We have not awarded this service a score for Effective.

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

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff had completed risk assessments for each patient upon admission. Women seeking early pregnancy scans had been contacted prior to their appointments to ensure the provider obtained additional information, including allergies, health conditions, previous infections, and estimated gestation. Staff demonstrated an understanding of and responded promptly to any immediate risks to people’s health.

The provider had implemented a robust process for identifying risks both prior to bookings and during scans, including the identification of previous ectopic pregnancies. Women had been encouraged to bring their NHS records to appointments to ensure sonographers had access to a complete medical history. The service had issued clear guidance for sonographers to follow when unexpected results were identified during scans.

Staff had provided examples of women referred into local NHS services and had known how to act swiftly in emergency situations. There had been 2 occasions in the last week when people had been referred to their local hospital, one of which had required an emergency ambulance for a suspected ectopic pregnancy. Women requiring referrals had been given their scan reports to share with NHS midwives or clinicians to ensure continuity and clarity of care. We saw reports were clear and concise and showed conclusions of what had been identified with a recommendation to seek further assessment in hospital or with a patient’s GP.

People told us, and we observed, that staff acknowledged their worries or anxiety and were proactive in offering support throughout the process. Staff had also allowed extra time during appointments to discuss concerns, especially where there had been a history of pregnancy loss. Women expressed satisfaction and some booked additional scans for later in pregnancy.

People attending early pregnancy scans had been asked about latex allergies in their health questionnaire, and we observed the sonographer checked this again before performing transvaginal scans using a latex sheath to cover the probe. Although pain levels had not been formally monitored due to the pain-free nature of the procedure, we observed staff asked asking women if they were comfortable during their scans.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

None of the individuals we spoke with raised concerns about the service’s ability to deliver evidence-based care and treatment. The service offered appropriate hydration and nutrition options.

Care and procedures were delivered in accordance with national guidance and evidence-based practice. We saw evidence that managers routinely monitored staff compliance with these standards.

The provider maintained responsibility for reviewing and updating policies in line with evolving best practice and national guidance. All staff confirmed they could access policies both online and in paper format. We observed that policies and guidance developed by the service were clearly indexed and methodically organised for ease of use.

Policy updates relevant to the service were cascaded and stored electronically for all staff to access. [JM1] Governance systems tracked policy changes and included reminders for scheduled reviews. Staff regularly reviewed guidance and alerts from authoritative bodies including the National Institute for Health and Care Excellence (NICE), the British Medical Ultrasound Society (BMUS), and the Society and College of Radiographers (SCoR), ensuring care remained aligned with current best practice.

The provider ensured adherence to ALARA (As Low As Reasonably Achievable) protocols, with clear guidance provided to people before and during scanning. Information about ALARA was prominently displayed in clinics. Review of scan documentation, peer reviews, and sonographer induction competence reports confirmed that sonographers routinely recorded compliance with ALARA principles, using the lowest possible output power and shortest scan times necessary to achieve diagnostic results.

Staff demonstrated familiarity with accessing relevant policies and procedures via the service’s online system. Updates to policies were discussed during team meetings and reinforced during daily huddles. Staff were given adequate time to review changes and confirmed they signed off to acknowledge understanding.

All policies reviewed were current and in date. The registered manager performed a monthly clinic visit and the clinic manager produced a monthly performance report. Performance against key indicators was shared with staff during monthly team meetings.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

We observed that all staff involved in care delivery worked cohesively to provide person-centred support throughout the patient journey. Team collaboration was evident across the service, with positive communication between managers and staff. A well-established daily handover process ensured that any issues or concerns were promptly addressed.

People using the service felt the team worked well together, highlighting good communication between the sonographer, chaperone, and the women and families. People we spoke with appreciated the team processes and staff understanding of each person’s needs and wishes. During the booking process, staff asked people to bring their NHS pregnancy records, enabling sonographers to access full medical histories, including details of previous fertility treatments and pregnancies. Service leads had access to all relevant online systems, ensuring timely access to information and scans when a second opinion was needed.

Staff from different roles worked together effectively to support people and their families. Scan assistants greeted people on arrival and worked alongside sonographers in the scanning room, each clearly understanding their role in the process. We observed them supporting each other and building a good rapport with the women and their relatives. After the scan, people were guided back to the waiting area where staff showed them how to download pictures via a secure app.

The service had developed pathways to support staff with referrals and next steps when unusual findings were identified during ultrasound scans. Staff understood their roles and responsibilities in ensuring timely referrals. Dedicated referral forms had been completed and reviewed by the registered manager to ensure accuracy.

The service maintained a positive working relationship with local NHS maternity services, referring women when abnormalities were detected during ultrasound scans. The clinic and registered manager confirmed that they had established contact with key staff from these organisations, fostering effective collaboration. We saw records of patient transfers to NHS care that noted effective contact with NHS staff.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

The service demonstrated a consistent and proactive approach to supporting individuals to lead healthier lives. Women using the pregnancy scan service told us that they received a wellbeing check at every appointment, which included discussions about both physical and mental health.

We observed that the service promoted health awareness through visible and accessible information. Posters providing domestic abuse support were displayed on toilet doors. Leaflets and signage outlined the signs and symptoms of breast and ovarian cancer. Information about morning sickness was available, including details on symptoms, contributing factors, and strategies to alleviate discomfort. The service also provided details about a telephone application designed to support women with pregnancy-related queries.

Leaflets promoting mental health and addressing anxiety were readily available. Staff demonstrated an understanding of the importance of reviewing not only the progress of pregnancies but also identifying and referring any potential gynaecological concerns. The service offered hormone testing to help women understand their fertility and likelihood of becoming pregnant.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Between 1 April 2025 and 31 March 2026, the clinic had a total of 4566 bookings and 4612 scans completed. Of these, 2527 scans were completed for Window to the Womb for gestations of 15+ weeks, 1508 were early pregnancy scans, 248 blood clinic bookings, 192 gynaecological scans and 137 non-obstetric scans with an overall rescan rate of 5%. Rescan reasons included ‘fetal position incompatible to provide accurate measurements or gender’, and ‘intermittent heartbeat’.

Although the service operated as a business with internal performance targets, people using the service consistently reported feeling valued and respected.

The clinic demonstrated a strong culture of continuous improvement. Monthly team meetings included discussions of audit results including scan quality and accuracy, as well as record keeping, and staff actively monitored the effectiveness of care. Findings were used to drive improvements and consistently achieve positive outcomes for people.

The clinic manager conducted regular clinical and environmental audits, focusing on key performance indicators (KPIs) such as incidents, inaccuracies, complaints, and scan times. These KPIs were set by the franchiser and used to benchmark performance against other clinics. The clinic consistently met scan targets.

Peer review was embedded in practice, with sonographers reviewing each other’s scans monthly. Evidence of this was seen during the inspection. Digital scan images were securely stored and shared for further review, ensuring high standards in image quality and equipment use.

A comprehensive audit programme tracked improvements over time. Audits consistently showed high compliance in areas such as scan quality, peer review completion, and environmental checks. Managers used audit data to enhance care and treatment. They conducted further audits covering physical clinic inspection, health and safety, infection control, emergency planning, operational delivery, policies and procedures, client feedback, and staff performance including sonographers. Action plans with completion timelines were developed in response to audit findings. We saw evidence that the clinic was compliant in all areas.

Staff were highly engaged and passionate, often exploring innovative approaches to improve outcomes. The clinic’s marketing—both online and in-person—emphasised care and compassion. Personalised displays, such as photos of scan images alongside new-borns, were voluntarily submitted by women and celebrated positive experiences.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

The service ensured that all people received comprehensive information prior to their scan. This included a technology and safety briefing, terms and conditions, scan limitations, a crib sheet outlining what was and wasn’t included in the scan package, and details regarding medical records, consent, and data usage. A pre-scan questionnaire and declaration form required women to confirm they were receiving appropriate pregnancy care and consented to information sharing with the NHS.

Upon arrival, people signed a wellbeing report confirming their consent to the scan. We observed this was then repeated and verified by the sonographer in the scan room. The service had a mental health policy in place to address frequent scan attendance. All staff had completed training on the Mental Capacity Act (MCA) and consistently applied its principles, including seeking consent and offering choices in line with MCA requirements.

Consent materials were available in multiple languages to support understanding, and staff clearly documented consent in patient records. Staff had access to detailed consent guidelines, including instructions for recording consent and identifying exceptions. Mandatory training included modules on learning disability awareness, ensuring staff were equipped to support diverse needs.

The service only provided procedures for individuals aged 16 and over and maintained an up-to-date consent policy. Staff were knowledgeable about assessing capacity and applying Gillick and Fraser guidelines appropriately. These guidelines help determine a young person’s ability to consent to medical treatment, with Fraser guidelines specifically addressing contraception and sexual health.

We saw that staff followed best practice in requesting and documenting consent. People were required to specify the type of scan they were attending, with this information included in confirmation letters and verified onsite. If a person was unsure, the consent process would be repeated to ensure full understanding.