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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm. Patient areas were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service managed patient safety incidents well.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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 that we spoke with knew what incidents to report and how to report them. We saw evidence of incidents the service recorded within the past 12 months, including the actions taken. The service recorded 6 incidents within the past 12 months, including ectopic pregnancies. The service also recorded all accidents that occurred within the service, but no accidents were reported within the past 12 months.

Staff had monthly team meetings to discuss how safety incidents were managed and where the service could make improvements from safety incidents that occurred. These meetings were attended by the clinic manager and sonographer. Staff were debriefed and received support after a serious incident.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. Staff also received specific training on how to deliver bad news to patients and their families, and they were encouraged to do refresher training where required.

Staff received feedback from investigation of incidents, both internal and external to the service. This included social services who liaised with the franchise regarding relevant safety investigations.

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.

The service worked with local authorities and social services to manage patient safety effectively. They signposted patients to the contact details of local NHS hospitals, if patients had any concerns prior to their appointment at the clinic and needed advice. Where patients were unhappy with their scans due to factors such as poor image quality, the service would offer a rescan at no additional cost.

The service had protocols in place for managing clinical risk, including a policy for responding to a missed or incorrect diagnosis. This policy included missed diagnoses subsequently identified elsewhere and incorrect diagnoses rectified by another healthcare provider. There was a clear investigation process to formally respond to the patient within set timeframes to apologise to patients, outline the findings and conclusions from the investigation, provide remedial action and offer further assistance if appropriate.

There was a clear process for escalating abnormal findings, including ectopic pregnancy diagnoses and obstetric emergencies. As part of the service’s emergency policy, staff were required to complete an emergency referral form and refer to these details when contacting emergency services. Staff were required to provide a copy of the referral form to the paramedics to ensure a smooth handover to emergency services, and staff recorded the incident in the clinic’s incident log.

The service signposted patients who experienced a miscarriage to external partners, such as the Miscarriage Association. The service encouraged patients who experienced loss during a pregnancy to receive sufficient ongoing support via helplines, live online chats, forums, and support groups. These support services were also available in other languages, for patients whose first language was not English.

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. All safeguarding referrals were logged and reviewed by the clinic manager to ensure appropriate follow-up.

The service had an up-to-date safeguarding adults and young people’s policy, and the policies were on display. The policy was updated annually and included signposting to other agencies where required. Staff understood their responsibilities and adhered to safeguarding policies and procedures. They notified local authorities and social services of any safeguarding incidents which required further investigation. The service would follow the duty of candour when things went wrong. Staff made notifications to external bodies as required, including serious incidents and duty of candour notifications.

The service maintained privacy and dignity of patients during their appointments. The service addressed the needs of patients from various cultural and religious backgrounds. For example, if a patient requested a female sonographer in advance, the service redeployed female sonographers to different clinic branches as needed.

We reviewed staff recruitment records, of which all required information was provided and records were in date. The service carried out monthly audits of recruitment checks, to ensure Disclosure and Barring Service (DBS) certificates were renewed where needed for the clinic manager and scan assistants.

The regional clinic manager oversaw mandatory training compliance for all staff. All staff were up-to-date with their mandatory training, which included adult and child safeguarding. Managers and sonographers were level 3 trained for safeguarding. All staff also received training regarding ectopic pregnancy, miscarriage awareness, the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), Female Genital Mutilation (FGM), Oliver McGowan Mandatory Training on Learning Disability and Autism, and General Data Protection Regulations (GDPR). We saw evidence that all staff were up-to-date with their mandatory training, and the regional clinic manager reviewed training compliance for all staff monthly.

The service ensured that sonographer staff had refresher training where required, which focused on learning following missed or misdiagnosed conditions, and where the sonographer would document the training and schedule additional peer reviews and service and care assessments.

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.

The service carried out comprehensive risk assessments for patients and assessed any risks, including risks associated with any pre-existing health conditions such as diabetes. The service had various protocols in place for emergency situations, where clinic managers were always present to call an ambulance for conditions identified such as ectopic pregnancies. The service also had policies and procedures such as an emergency action plan and clinic contingency action plan. This covered various situations such as cover for staff absence, equipment failure, utility disruption, and extreme weather conditions.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities, and technology supported the delivery of safe care. All equipment was serviced regularly, such as scan machines and fire alarms and extinguishers, and electrical equipment was portable appliance tested (PAT) with the stickers on display and in line with manufacturer guidance. Staff completed risk assessments in relation to fire safety, infection prevention and control, and the control of substances hazardous to health (COSHH), and ensured all of these assessments were up-to-date.

The clinic was clean, well maintained and suitable for its purpose. Staff ensured the safe disposal of clinical waste, differentiating this from general waste and both clinical and general waste was disposed of daily.

However, due to limited space within the clinic, there was no dedicated quiet room for patients and their families to use for sensitive situations, for example if the sonographer had to deliver bad news and if patients and their families were distressed. Staff recognised the need for people’s privacy and managed this by allowing patients and their families to remain in the ultrasound room for as long as they needed. Staff would apologise to other patients accordingly for potential delays in being seen by the sonographer.

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. Staff appraisals took place between sonographers and the area manager, so staff received the support they needed to deliver safe care. All sonographers were registered with the Health and Care Professions Council (HCPC) and were also members of the Society of Radiographers (SoR).

Ongoing competency of staff was assessed by regular scan reviews and assessments by the service’s clinical lead sonographers. We reviewed evidence of regular audits of scan quality and reporting accuracy from the past 12 months, where staff carried out thorough audits of different scan types and samples such as gender scans, reassurance scans and 4D scans. Staff assessing the scans outlined areas of good practice and identified actions and areas for improvement, including the need to always document in the sonographer’s report whether the patient self-referred to the service or was referred by a clinician.

The service promoted staff wellbeing and encouraged staff to take regular breaks. They ensured flexible cover was provided where needed, for example if a member of staff was absent from work due to illness, they would ensure that another member of staff within the clinic franchise was available to cover at the service. Where required, the service used locum staff for sonographers, but the service did not need to use locum staff often.

The service ensured that sufficient planning arrangements for staff were in place. They had a rota system, where staff were notified 4 to 6 weeks in advance of their shifts, whilst also considering factors such as annual leave.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff adhered to bare below the elbow protocols. Sonographers wore gloves and were given the option to wear face masks. The service carried out regular deep cleaning at the end of the clinic’s opening hours. We reviewed cleaning records of privacy screens, scanning machines and ultrasound probes that the sonographer would clean, which were up-to-date.

We also reviewed data of hand hygiene audits within the past 12 months which showed 100% compliance with hand hygiene standards amongst all staff employed at the service, and observed up-to-date cleaning logs of toilets and basins within the scanning room. Staff were also aware of the importance of having hair tied back and frequent hand washing, and hand sanitisers were available throughout the service.