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

We looked for evidence that people were protected from abuse and avoidable harm, the service managed risk, the environment was well maintained and the service had enough qualified staff.

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.

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.

The service had a clear and effective incident reporting process. Staff clearly understood their roles and responsibilities in reporting concerns and documenting safety incidents. The service managed safety incidents well and learned lessons from them. 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. The service kept a log of clinical incidents, of which 4 were recorded from the beginning of the year. Three of these incidents were recorded following the identification of ectopic pregnancy, 1 was more serious. For medical emergencies, the staff followed their policy, organised hospital transfer and provided these patients with follow up and after care. Staff told us they were debriefed and supported after an incident, particularly where the situation was sensitive.

Managers created a culture that encouraged the raising of safety concerns. All incidents were reported to the clinic manager and logged. We saw evidence of reporting and a log of reported incidents. The service had a comprehensive incident policy, and staff were aware how to report incidents and the appropriate timeframes for reporting. This enabled effective oversight, action tracking and monitoring through weekly and monthly meetings. Learning was shared through team meetings, emails and staff information boards.

Staff understood the duty of candour and the service had a policy in place. Staff described a no-blame culture and were open and honest, when concerns were raised.

Local policies and processes were up to date and aligned with national guidance. This included standards from the Royal College and Society of Radiographers, the Fetal Abnormality Screening Programme (FASP) and the British Medical Ultrasound Society (BMUS).

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 was available to adults (18 years old or over). The terms and conditions of the service state a child (aged 16 or 17 years old) may be scanned but was required to attend with a responsible adult. The service had a clear definition of a responsible adult. The service did not scan children under the age of 16. Staff checked the patients age before scanning and completed ID checks. Staff were familiar with the criteria for refusal to scan and the service had a clear policy to underpin this. The service had comprehensive policies and procedures for all types of scan undertaken. Additional services offered included Non-Invasive Prenatal Test (NIPT), gynaecological scans and early pregnancy scans.

People were able to make appointments over the phone, on the website or in person. The service used an electronic booking system, which was monitored daily. Weekly reviews took place to ensure all necessary information was in place for safe scanning. Clear operational policies guided the booking process. Staff and managers told us that they were able to work across local clinics, supporting flexible opening hours, including evenings and weekends.

The service used the ‘Pause and Check’ checklist from BMUS and Society of Radiographers. Sonographers completed checks during scans, confirming identity and consent, providing clear instructions, and explaining results. People 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.

A pre-scan questionnaire was completed by all patient’s using the service. Patients provided signed consent to share medical information, if needed, with local NHS providers. Clear pathways were in place with local NHS providers for referrals, when abnormalities were detected. If an abnormality was found during the scan, the sonographer explained findings to the patient and the scan assistant documented the report. Patients chose who they would like to stay in the scan room for the discussion of the results. If further investigation was required, the sonographer would refer the patient to the appropriate NHS Foetal Medicine Unit (FMU) or Early Pregnancy Unit, ensuring the patient understood the referral process before leaving the clinic. Staff followed up appropriately where they identified concerns and a person left the clinic immediately after their scan and did not wait for the report, image or any further information. The service made a referral to the local NHS Early Pregnancy Unit (EPU) as directed by their policy and an email sent to the patient with details of the report, referral and information regarding missed miscarriages. Staff followed incident reporting processes to ensure management was informed. The service had a flow chart for staff to follow, based on scan outcomes, and clear guidance for patients diagnosed with an ectopic pregnancy. For general health scans and blood tests, staff would provide a written report for people that they could take to their GP if they wished to obtain diagnoses. Staff made courtesy follow-up calls to patients after they had been referred on to other services.

All staff had received advanced level first aid training and a fully stocked first aid box was available. A resuscitation trolley was not required due to the nature of the service. Policies were in place for managing patient deterioration. Staff told us they would follow the emergency action plan and call 999 for hospital transfers.

The service worked with people and healthcare partners to understand what being safe means 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 staff had completed level 2 safeguarding training for children and adults. Managers were trained to level 3, with 100% compliance. The registered managers were the safeguarding leads for the service. The safeguarding policy was written in line with intercollegiate documents for safeguarding children and adults. This ensured staff had clear guidance for identifying and reporting concerns. Staff told us they knew how to refer if they had concerns. Managers told us they had a franchise safeguarding lead, trained to level 4, who they could contact for support and advice when needed. Staff understood domestic abuse and were equipped to support people experiencing difficulties. Information was placed in discreet areas of the service providing details of a 24-hour, confidential helpline and website details. No safeguarding incidents had been reported in the 12 months prior to assessment. All staff and managers had completed training on female genital mutilation (FGM) and the Mental Capacity Act (MCA).

We reviewed 7 staff files, 6 of these files contained Enhanced Disclosure and Barring Service (DBS) checks completed at the start of employment and were current and up to date. The registered manager was responsive and processed an application for the member of staff who did not have a current DBS check. The member of staff had changed job role, hence the omission of the checks. The DBS policy acknowledged that circumstances could change after a check was completed; therefore, staff were never left alone with people, and at least two staff members were always present during scans.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs in a way that was safe and supportive and enabled them to do the things that matter to them.

Information was gathered through a pre-scan questionnaire, including pregnancy and medical history. There was a free text box for the patient to share additional information with the sonographer. The fetal well-being report prompted the sonographer to record if the patient presented their hospital notes, who they attended the appointment with and if the sonographer was satisfied that the service was appropriate for the patient.

Informed consent was gained prior to the scan which was very clear to the scope and limitations of a well-being scan. This included information on risks, responsibility to attend NHS scans and translation or additional support, if English was not the patient’s first language. Information was also included about the procedure if an NHS referral was required. This ensured people were involved at all stages and understood their care.

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 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. The ALARA principle is a safety rule used in medical imaging and radiation work to make sure radiation doses stay very small. Standard operating procedures were visibly displayed in scan rooms for easy reference and to remind staff of checks to complete before scanning. Staff made it clear to people that blood tests were processed by an external company solely responsible for any diagnosis and follow-up advice, guidance, or treatment.

The service had a Deteriorating Patient Policy in place and staff demonstrated they had the knowledge and skills to act appropriately if faced with this situation. An example was provided of a patient collapse during a blood test; staff described how the situation was managed and the patient kept safe. The registered managers told us they had been trained and could perform cardiopulmonary resuscitation (CPR) in an emergency. The service had a clear Escalation Policy in place that staff were familiar with.

The service had systems in place to identify and mitigate risks. We saw evidence of up-to-date risk assessments completed for first aid, 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.

The service detected and controlled potential risks in the care environment. They made sure that the equipment, facilities and technology support the delivery of safe care.

The premises were clearly identifiable with a prominent sign displayed above the entrance. Roadside parking was available in the immediate vicinity of the service and no difficulties with parking were observed during our assessment. There were clear directions, on the website, for people attending using public transport and people told us the service was easy to find. The service was light and spacious, and located on the ground floor. There was a small step at the entrance; however, this did not present a barrier to access for individuals using pushchairs or wheelchairs. There was privacy screening on the windows in the seated waiting areas. Internal access throughout the service was level, with no additional steps observed within the premises. The service had appropriate facilities and sufficient equipment to meet the needs of people. Disabled toilet facilities and a baby changing station were available for people visiting the service.

We saw evidence that staff carried out regular checks of stock, first aid kits, and equipment. The service had a clear Health and Safety policy and staff were familiar with this. All electrical items had undergone safety testing within the previous 12 months. Managers ensured timely maintenance and servicing of the ultrasound machine in line with their Quality Assurance (QA) policy for ultrasound machines. New staff members were provided with induction training on the machine operation and QA protocols, with annual professional development sessions covering new techniques and updates to QA procedures. Ultrasound machine settings were pre-configured by the manufacturer (GE) to comply with the ALARA principle.

Daily, weekly and annual checks were completed on the ultrasound machine. The checks were completed in line with the QA procedures documented in their policy to ensure the safe, effective and accurate operation of the ultrasound machine. This meant the service met the guidelines from the manufacturer.

The scan room was spacious and comfortable. There was an adjustable height couch that met recommended standards and adjustable height seating for staff. Comfortable, cleanable seating was available for additional people attending the scan. Lighting could be dimmed and there was a large television screen positioned for people to see their scan in real time. Additional privacy screening was available within the scan room itself. The door could be locked to ensure privacy.

Environmental audits were in place, including fire alarm testing and evacuation drills. Fire extinguishers were accessible, correctly stored and checked in line with the policy. We saw all electrical equipment was labelled with current portable appliance testing (PAT) checks. All equipment was stored according to guidelines, for example, gels and blood taking equipment. The COSHH cupboard was clearly marked and secured. Sharps and waste were disposed of in a way that kept people safe. Staff used appropriate systems to separate clinical and non-clinical waste and was disposed of safely under a contract with a third-party provider.

Personal Protective Equipment (PPE) and hand gels were readily available throughout the premises. Staff told us the whole team was responsible for cleaning, with schedules in place. We saw daily and monthly audits recording cleaning of the premises. People using the service described the premises as clean, 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 systems in place to ensure safe and effective staffing, underpinned by a comprehensive policy which detailed their recruitment process. This included the selection and interview process, background checks, verification of professional registration, and competency assessments. We saw a structured induction process was in place for new staff, including corporate and clinical skills training, and job descriptions were clear. 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. Training records and evidence of ongoing Continuous Professional Development (CPD) were maintained in the staff member’s file. We reviewed the training matrix and saw all staff were up to date with all training.

At the time of assessment the service was fully staffed with no vacancies. The service had enough staff to keep people safe. Staffing levels ensured there was no lone working and chaperones could always be provided if required. No bank or agency staff were used. Sonographer cover could be flexible by relocating staff from other clinics within the group. All sonographers were registered with the Health and Care Professions Council (HCPC) with current certification held in the staff member’s file.

Ongoing supervision included reflective practice, personal development and care discussions. We reviewed content of regular 1:1 meetings and saw training was discussed at each meeting. Sonographers had clinical supervision and training updates with the clinical lead sonographer and peer support from other sonographers across the group.

Development opportunities were available for staff, for example phlebotomy training. We saw evidence of staff taking these opportunities, extending their skills and developing into new roles.

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

The service controlled infection risk well. Staff used equipment and control measures to protect themselves and others from infection. They kept the equipment and premises visibly clean. All staff had bare arms, below the elbow, in accordance with National Institute of Health and Care Excellence (NICE) guidance and the service’s own policy. We saw staff had access to ample supplies of PPE and handwashing supplies. We saw handwashing technique posters clearly displayed in accordance with NHS England ‘5 moments’ guidance. Staff accessed up to date Infection Prevention and Control (IPC) policies. IPC audits were completed and reported every month and included, for example, hand hygiene, machine filter cleaning, privacy curtain replacement and environment audit. We saw completed, in full, the audit data for the year to date. People using the service had no concerns regarding cleanliness and handwashing.

All furnishings could be wiped down and were well maintained. The couch could be wiped down and the service also used paper roll on top of this. Spill kits were available for cleaning of any bodily fluids.

Ultrasound probes were cleaned by sonographers who recorded information of the products used to clean probes, including batch numbers and expiry dates. The ultrasound machine was cleaned at the end of each day. All equipment for blood taking was stored securely and in individual sealed boxes. All storage and transportation of bloods followed appropriate procedures. Staff were familiar with the management of sharps injuries and the process was clearly documented in the IPC policy.

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