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

The service had a positive learning culture and staff and patients could raise concerns. There were enough staff with the right skills, qualifications and experience to ensure high quality care and treatment. Staff were trained in key skills, safeguarded people from abuse, and managed safety and infection risks effectively. Staff carried out risk assessments, documented them appropriately, and made sure there was continuity of care, though effective record keeping. The facilities and equipment met the needs of patients, were visibly clean and well-maintained. Potential risks in the care environment were identified, managed, and sufficiently mitigated. Safety incidents were managed well, with learning shared across the team and other Window to the Womb clinics in the group in the Northeast and Northwest of England.

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.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff consistently recognised and reported incidents and near misses, supported by a culture that encouraged the raising of safety concerns. They clearly understood their roles and responsibilities in reporting concerns and documenting safety incidents. Incidents were logged, which enabled effective oversight, action tracking, and monitoring through weekly and monthly meetings. This system also facilitated the identification of recurring themes and trends.

Managers told us that learning from incidents was shared with staff both within the clinic and across the wider service. Lessons learned from other Window to the Womb locations were also disseminated to all staff.

Staff told us there was a clear and effective incident reporting process. However, there were no entries in the last 12 months. A duty of candour policy was in place, and staff described a no-blame culture. They demonstrated a clear understanding of the duty of candour, showing openness and honesty should things go wrong.

All incidents would be reported to the clinic manager and documented. Learning was shared through staff information boards, emails, and team meetings.

The clinic had recorded zero never events and no incidences of clinic-acquired infections.

No formal complaints had been received in the past 12 months. Staff collected verbal and informal feedback and concerns from people. In response. An example of making changes included, the clinic implemented changes in practice: such as ensuring they communicated to keep a baby’s gender secret until the parents wanted it to be revealed. Evidence showed that this change was being actively monitored. We observed staff providing a blank, sealed envelope containing details of the baby’s gender so that the parents could take it somewhere private to open in their own time, or to share the surprise with relatives.

Local policies and protocols were up to date and aligned with national guidance. This included standards from the Society and College of Radiographers, the fetal abnormality screening programme, and the British Medical Ultrasound Society.

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.

We saw the provider’s electronic booking system was monitored daily, with weekly reviews to ensure all necessary information was in place for safe scanning. People booked appointments online via a 24/7 platform or by calling the clinic directly. The franchise model enabled staff to work across local clinics, supporting flexible opening hours, including evenings and weekends. Clear operational policies guided the booking process.

People we spoke with reported good communication between the clinic and NHS maternity teams regarding scan results, referrals, and information sharing. The booking system issued automatic appointment reminders and allowed short notice rebooking in cases such as work or family commitments. We saw evidence that managers followed up with people who did not attend.

Sonographers at this location could access support from other services within the Window to the Womb Franchise as they used consistent systems and communication channels. Patient records were comprehensive, securely stored on an encrypted electronic database, and accessible to all staff. Staff could view records from other clinics, providing insight into previous scans and exposure to ultrasound.

Policies were in place for managing patient deterioration. All staff were trained in adult resuscitation and basic life support. Staff told us they would follow the emergency action plan and call 999 for hospital transfers. One emergency transfer following diagnosis of an ectopic pregnancy had occurred in the week prior to our on-site inspection.

The service used the ‘Pause and Check’ checklist from the British Medical Ultrasound Society and Society of Radiographers. Sonographers completed checks during scans, confirming identity and consent, providing clear instructions, and explaining results. Women with later gestations were advised to bring NHS pregnancy notes. Staff ensured women understood that scans were supplementary to routine maternity care and advised those who had missed a booking appointment they should register with their local maternity unit.

All people who used the service completed a pre-scan or medical history questionnaire depending on the type of service they wanted. This included a signed declaration confirming NHS care and consent to share medical information if needed. Clear pathways were in place with local NHS providers for referrals when abnormalities were detected. For general health scans and blood tests, staff would provide a written report for people that they could take to their GP if a diagnosis was wanted.

If an abnormality was found, the sonographer explained findings to the patient or the parent(s), and the scan assistant documented the report. People were given a copy to take to hospital or their GP. In suspected ectopic pregnancies, staff called 999 for ambulance transfer. Staff told us that the ambulance response time was sometimes lengthy, and they felt the ambulance staff had not taken the mother’s condition seriously enough. However, in the ectopic pregnancy that had occurred in the last week, the ambulance had arrived promptly and had transferred the mother straight to the local hospital for emergency care.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The registered manager was the designated safeguarding lead. The service had a comprehensive safeguarding policy with clear guidance for identifying and reporting concerns. All staff completed safeguarding training, with 100% compliance at Level 3 for vulnerable adults. Training included the Mental Capacity Act and female genital mutilation (FGM), integrated into both adult and children’s safeguarding modules. Staff were aware of safeguarding procedures and the policy and explained how they would refer if concerns were raised. The recruitment policy acknowledged that circumstances could change after a Disclosure and Barring Service (DBS) check was completed; therefore, staff were never left alone with people, and at least two staff members were always present during scans.

Staff scanned people aged 18 and over, and those aged 16–18 if the patient was accompanied by a parent. No children under 16 were scanned. Date of birth was confirmed at booking, and identification was required at the appointment. Staff reported they would rebook a scan if a patient forgot their ID.

Safeguarding posters and leaflets were displayed throughout the clinic, including materials from a national domestic violence charity in the toilets. No safeguarding incidents had been reported in the 12 months prior to inspection.

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.

People we spoke with understood they could not have more than one scan every two weeks and were advised not to attend scans during the 18–21-week window to avoid interference with the NHS 20-week anomaly scan.

Staff were aware of their responsibilities in documenting scan type and frequency and in advising people about the potential risks of ultrasound overexposure. Scanning time was limited to 10 minutes in line with British Medical Ultrasound Society (BMUS) guidelines. Staff adhered to ALARA (As Low As Reasonably Achievable) principles, consistent with the Society and College of Radiographers’ 2017 Guidelines for Professional Ultrasound Practice. Standard operating procedures were visibly displayed in scan rooms for easy reference.

Telephone assessments were conducted to support triage, identify risks and needs, and arrange face-to-face appointments. Staff clearly described exclusion criteria.

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 clinic was spacious, well-lit, and located on one floor with bespoke rooms designed by the staff. All flooring was washable and hygienic with anti-slip surfaces. The service had appropriate facilities and sufficient equipment to meet the needs of people.

We saw evidence that staff carried out regular checks of stock, first aid kits, and equipment. Daily quality assurance checks were completed on the ultrasound machine to ensure safe operation. A resuscitation trolley was not required due to the nature of the service. A fully stocked first aid box was available, and rotas ensured staff with adult and paediatric first aid qualifications were always on duty. Electrical items had undergone safety testing within the previous 12 months, in line with the provider’s safety policy. Managers ensured timely maintenance and servicing of the ultrasound machine. Fire extinguishers were accessible and correctly stored, with clear fire exit signage. Faults and low stock were reported to the clinic manager through a clear process. All consumables reviewed, including scanning gels, were in date except for one box of blood collection bottles. However, staff told us these were used for staff phlebotomy training only. These were removed from the store immediately. No other faults or concerns were identified during inspection. Clinical waste was disposed of safely under a contract with a third-party provider.

The reception area was clean, secure, and well-maintained, with controlled door access and CCTV coverage. Reception staff maintained a clear line of sight. The waiting area included some clean and well-maintained toys and information leaflets for those attending the clinic.

Personal Protective Equipment (PPE) and hand gels were readily available throughout the premises. Staff completed daily cleaning checks, with signed and dated records observed. Communal areas were clean and well-presented.

The scan room contained a clean, adjustable surgical bed that met recommended standards. A dedicated quiet room was available for sensitive conversations in a private setting. Environmental audits were in place, including checks on fire extinguishers, fire alarm testing, and evacuation drills. All equipment was labelled with current portable appliance testing, and scanning equipment, including probes, was serviced and calibrated according to manufacturer guidelines.

The service had systems in place to identify and mitigate risks. We saw evidence of up-to-date risk assessments completed for fire safety, health and safety, hand hygiene, legionnaires’ disease, and Control of Substances Hazardous to Health (COSHH). Each assessment identified risks, control measures, and the staff member responsible for monitoring. Organisational risks were also documented. Emergency action plans were in place for incidents such as power failure or fire, with clear staff instructions and contact details.

People using the service reported no issues with equipment and described the premises as safe, well-maintained, and suitable for their visit.

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.

The service had enough staff to keep people safe. At the time of inspection, the service was fully staffed with no vacancies. Daily staffing requirements were calculated by the clinical manager and reviewed in advance. People using the service reported satisfaction with staffing levels, and people appreciated the presence of a scan assistant who was trained to act as a chaperone at every appointment.

Recruitment processes included background checks, verification of professional registration, and competency assessments. We reviewed 3 staff recruitment files, and all records showed staff had Enhanced Disclosure and Barring Service (DBS) checks completed at the start of employment. Clear job descriptions outlined roles and expectations. All eligible staff had received annual appraisals, and managers addressed poor performance appropriately. Training was delivered via an online system, tailored to individual roles, and covered mandatory subjects and professional interests. We saw a structured induction process was in place for new staff, including corporate and clinical skills training.

All staff had completed mandatory training in the past 12 months. We saw evidence that training records were up to date. Some staff were directly employed on zero-hours contracts to suit other commitments and provide a good work - life balance. Scan assistants managed enquiries, bookings, supported sonographers during scans, and assisted families with printing scan images. No bank or agency staff were used. The sonographer carried out pregnancy scans and some specialist scans such as prostate and thyroid scans. Sonographer cover could be flexible by relocating staff from other clinics within the group. A second sonographer was employed with locum status and would carry out specialised scans such as breast scans.

Staff files we reviewed were complete, with employment checks and references documented. Induction training and initial assessments for sonographers had been completed.

Ongoing supervision included reflective practice, care discussions, and personal development. Regular team meetings supported communication and service improvement. All sonographers were registered with the Health and Care Professions Council (HCPC), and this was confirmed in the registration log. Sonographers had clinical supervision and training updates with the clinical lead sonographer.

Development opportunities were available for staff, including roles in telephone support and bereavement training as well as phlebotomy training. Staff described opportunities to extend their skills and the potential to develop into other roles.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading, although they did not always check stock of consumables and expiry dates. They shared concerns with appropriate agencies promptly.

All areas of the clinic were visibly clean, well-maintained, and appropriately furnished. Handwashing sinks and sanitising gels were readily available, and staff followed hand hygiene protocols and ‘bare below the elbow’ guidance. Personal Protective Equipment (PPE) was accessible and staff used it appropriately. We saw evidence of hand hygiene audits being carried out.

People using the service told us the premises were clean and tidy, with no concerns raised about environmental or equipment cleanliness.

Staff followed the IPC policy, completed mandatory training, and demonstrated strong understanding of IPC risk management. Staff stated the manager was vigilant about cleanliness, and daily inspections were carried out before scanning lists began. Ultrasound probes were cleaned with sanitising wipes after each scan, and the ultrasound machine was cleaned at the end of each day. Staff cleaned transvaginal probes appropriately with high-level disinfectant gel between uses. Batch numbers and expiry dates were recorded on each patient record form.

Clinical waste was disposed of safely using appropriate bins, which were emptied into external clinical waste containers under a third-party contract.

All areas of the clinic, including high and low surfaces, were found to be clean during inspection. A dedicated COSHH cupboard was securely locked, and chemicals were stored in line with legislation.

Blood kits were individually wrapped, centrally ordered, and returned for destruction via a third-party provider. All storage and transportation of bloods followed appropriate procedures.

In the store room we found a box of blood vials that were out of date. We showed these to staff who explained they were not used for people using the service, but for phlebotomy training only. However, they were stored with the vials for patient use. From this evidence it was not clear if the service operated a clear and effective stock check or rotation system. We asked the clinic manager to remove the out-of-date equipment, and this was done immediately.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.