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 Outstanding. At this assessment the rating has changed to Good.

This meant the service was consistently managed and well-led.

We found leaders were open and honest and promoted high-quality, person-centred care. Reliable information systems supported service delivery and staff development. There was a culture based on speaking up, listening, learning and trust. Staff enjoyed working at the clinic and felt empowered to make suggestions for improvement. Staff felt positive about their immediate leadership team.

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.

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.

Staff consistently reported high levels of motivation and positivity about their roles. They described a culture that was friendly, safety-focused, and open, and stated they received strong support from managers. Staff described teamwork as effective, and the working environment as encouraging.

Staff spoke of an open and honest culture within the service and were overwhelmingly positive about their experiences. All staff we spoke with told us they enjoyed their work and valued their team and managers. They felt proud of the service they offered. Staff understood the goals and ethos of the Window to the Womb franchise.

During the inspection, we observed visible leadership. Managers engaged readily with all staff and with the people using the service. They demonstrated a clear understanding of service-specific and wider sector challenges and priorities. Staff reported that leaders ensured staff and managers were equipped with the necessary skills, training, and experience to fulfil their roles. Bespoke training was provided by the franchise to support this.

There was a systematic approach to monitoring and reviewing progress against strategic plans. These plans were consistently implemented and had a positive impact on service quality and sustainability. The registered manager articulated the franchise strategy and future plans clearly, including defined objectives for growth and sustainability. The clinic manager demonstrated commitment to achieving the best outcomes for women, and the service vision had been developed collaboratively with service users and external partners.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff spoke highly of both the registered managers and clinic manager, describing them as approachable and supportive. They reported feeling comfortable raising concerns and stated that managers supported their career development and promoted a healthy work-life balance.

Staff could access counselling and advice through an employee assistance helpline, and the most recent staff survey results showed staff were aware they could access it.

Managers at all levels were described as having the appropriate skills, experience, and abilities to lead a sustainable service. Staff, including scan assistants, reported that company directors and the area manager were visible and approachable, visiting the clinic periodically to conduct audits and engage with staff.

Leadership development was embedded within the service, supported by a clearly defined leadership structure. One of the registered managers also held the role of franchise owner. The clinic manager led the Chester le Street clinic operationally and was responsible for day-to-day service delivery. Staff reported that this structure worked well.

Senior staff provided support across all clinics nationally and demonstrated flexibility and continuity in their approach. Staff expressed pride in working for the organisation and spoke positively about the culture. During the inspection, staff were observed to be friendly, confident, and welcoming. They expressed pride in their roles and in the quality of care provided. Staff morale was positive, and women using the service described staff as consistently friendly and helpful.

The most recent staff survey feedback from January 2026 showed that staff wanted to see more of the Directors and Senior Management. The registered manager reported “We changed our structure at the beginning of the year anyway, adding in the Regional Managers, so teams see their Regional Managers, and leaders at least once a month. However, when visiting clinic on a shift we often saw the same staff members rather than the whole team. We have now implemented informal quarterly meetings, where the whole team is invited and all the leaders visit. This is to discuss clinic positives, ideas, any issues they currently have and just to make sure everyone has that opportunity.” “We had previously done a wellbeing survey which focused more on work/life balance and from that we signed up to an app that allows you to set days off and working hours so it’s less intrusive in their life when they are off work.”

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 of reprisal. This was supported by clear policies and accessible leadership. Staff reported feeling confident in raising issues should these occur.

A Freedom to Speak Up (FTSU) policy and guardian were in place and accessible to all staff. The policy outlined the process for speaking up and what staff could expect in return, promoting transparency and support. All staff were aware of the FTSU guardian. A corporate FTSU poster was displayed in staff areas.

Staff stated they could approach managers with concerns and described the management team as having an “open door” approach. This had improved recently when the regional manager had begun to visit each clinic on a regular basis.

An equal opportunities policy was in place to support fair decision-making and prevent discrimination. It addressed both direct and indirect discrimination.

A whistleblowing policy was up to date, although staff told us they had not had reason to use it in the previous 12 months.

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.

The service promoted a highly inclusive and fair culture, where diversity was valued and staff felt heard, supported, and respected across all roles. Its commitment to equality and inclusion was evident through its policies, support mechanisms, and proactive efforts to promote staff wellbeing and celebrate achievements.

Staff advised us they felt there was equal opportunity for career progression and promotion regardless of background or whether staff had a protected characteristic.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The clinic manager demonstrated a clear understanding of service-related risks and met regularly with the registered and area manager to review performance.

Governance arrangements were regularly reviewed and reflected best practice. The provider adopted a systematic approach to working with external organisations to improve care outcomes and ensured policies aligned with national guidance and emerging sector standards.

The registered manager held overall responsibility for clinical governance, supported by franchise directors. The governance framework enabled staff to deliver safe and effective care and was tailored to the nature of the service. Senior leaders held designated roles, including safeguarding leads and policy oversight.

The registered manager maintained oversight of recruitment, regulatory compliance, and equipment and premises maintenance. All sonographers held relevant registration and sector qualifications. Local managers worked closely with the provider’s senior team to ensure sonographers participated in a structured audit and peer review programme.

Policies were clearly indexed, comprehensive, and accessible to staff. Personnel and training files were maintained in paper format and audited monthly. Governance systems were overseen by the franchiser, who conducted a full catalogue of audits.

Staff maintained confidentiality by locking screens, securing printed materials, and speaking discreetly. We saw evidence that all staff were up to date with mandatory training in record keeping, information governance, and cyber security. The service had a data protection and retention policy aligned with national guidance, and personal data was destroyed accordingly.

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 engaged with people through informal interactions, patient surveys, and feedback forms.

Staff emphasised the importance of delivering high-quality services for people alongside NHS provision. The registered manager described strong relationships with NHS colleagues and local NHS services. They had experienced some difficulties accessing quick transfers for women experiencing ectopic pregnancy and had offered to educate and talk to ambulance staff about the urgency required to prevent severe harm in ectopic pregnancies.

The service promoted continuity of care and community engagement, and the service explored ways to support women post-pregnancy across the region. The provider shared community engagement and feedback with each clinic. There had been face-to-face sessions with local groups such as paediatric first aid, baby yoga, and toddler groups. We saw evidence that these regional initiatives had received positive feedback.

Staff participated in fundraising events for charities linked to the service, including those focused on gynaecological cancer and miscarriage. This activity was supported by the franchiser.

The provider’s social media platform was centrally managed, with oversight from the clinic manager. The team developed innovative approaches to using social media for information sharing.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider was involved in carrying out continual research in partnership with Durham University. The current project was to measure the effect of e-cigarette use on the unborn fetus. Women were asked if they would like to take part in the research and there was no coercion or obligation to do so.

The service was proactive in exploring new partnerships and technologies to enhance people’s experiences. The service offered blood tests for antenatal gender testing as well as fertility and hormone tests and a range of general health areas including prostate tests. Staff, trained in phlebotomy, took bloods and sent kits to a laboratory for testing, assessment, and reporting. Reports were sent direct to patients. There was a service level agreement (SLA) in place with the laboratory.

Staff we spoke with described a strong commitment to continuous learning and service safety and improvement.