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

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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.

The service had an organisational strategy and a vision and values statement. Staff were familiar with and understood the visions and values. Staff worked consistently to achieve provision of ‘an exceptional service to a diverse community with safety and compassion at the heart of everything’ they did. All staff we spoke with told us they were proud of their service and the work they did.

We heard how leaders promoted an open and supportive environment where staff felt able to raise concerns and share ideas, without fear of blame. Staff told us they felt listened to, respected and supported by their managers. They spoke highly of colleagues and managers and described strong teamwork, with a shared focus on delivering high quality, person-centred care.

During the inspection, we observed visible leadership. Managers engaged readily with all staff and 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 service demonstrated commitment to achieving the best outcomes for women, and the registered manager explained 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.

The service was led by a team with the appropriate skills, experience and integrity to deliver high quality, person-centred care. Leaders demonstrated a good understanding of their service. They were able to describe how they managed priorities, responded to pressures and made decisions to maintain safe and effective care.

Staff were encouraged to develop their skills and take on additional responsibilities, with access to training, mentorship and career progression opportunities.

Leaders were visible and approachable, with staff reporting that they felt supported and able to raise concerns or share ideas. Staff described a positive leadership culture that was inclusive and respectful where their contributions were valued.

The leadership team demonstrated a compassionate and supportive approach, recognising the emotional demands that sometimes arose when providing this type of care. They promoted staff wellbeing and took steps to understand and address the challenges faced by those in patient-facing roles. A counselling and advice service was provided through an employee assistance helpline, all staff we spoke with knew this was available to them for help and support, as needed.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had a whistleblowing policy that encouraged staff to raise concerns confidentially without fear of retribution. Alternatively, staff were directed to appropriate other services for support with raising concerns. Staff told us that they all felt equally valued and comfortable to raise any concerns. A corporate FTSU poster was displayed in staff areas.

The registered manager was readily available to meet with people raising concerns and was passionate about ensuring there was a culture where people felt they could speak up and have their voice heard.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The service demonstrated a commitment to promoting equality, diversity and inclusion within its workforce. Staff described a culture that was respectful and inclusive, where individuals from different backgrounds felt valued and treated fairly. Leaders promoted equality in day-to-day practice and took steps to ensure staff with protected characteristics were supported and able to contribute fully to the service.

There was an equality, diversity and inclusion policy in place and all staff completed training that supported them to deliver care in line with the policy. This ensured people with protected characteristics as defined in the Equality Act 2010 were able to receive care without bias.

The registered manager made sure that all staff had access to appraisals regardless of role and responsibilities. Staff told us they felt there was equal opportunity for career progression and promotion regardless of background or whether staff had a protected characteristic. We saw an example of a member of staff initially employed as a print assistant, supported to complete phlebotomy training. On completion of the training and competency checks the member of staff now leads the blood testing service provided.

Flexible working arrangements were available, and we heard reasonable adjustments would be considered when needed although this had not been needed for any staff since opening. The registered manager was able to give examples of considerations where reasonable adjustments or flexibility may be needed.

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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The service had governance and management systems in place, with defined roles, responsibilities and lines of accountability across all levels. Staff were aware of their roles and described clear oversight from managers. Managers had a clear understanding of service-related risks and met regularly with the area manager to review performance. The overall responsibility for clinical governance was held by the registered managers and supported by the area manager and franchise support.

The governance framework enabled staff to deliver safe and effective care and was tailored to the nature of the service. Managers held designated roles, including safeguarding leads and policy oversight. They also maintained oversight of recruitment, regulatory compliance, equipment and premises maintenance. All sonographers held relevant registration and sector qualifications. Managers worked closely with the franchise network senior support team to ensure sonographers participated in a structured audit and peer review programme.

Policies were stored online with paper copies also available, and all were stored securely. We reviewed policies and saw they were clearly indexed, comprehensive, in line with best practice guidance and accessible to staff.

There was a clear framework for team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. We saw evidence of monthly clinic meeting minutes, with staff sign off sheets, to confirm attendance. Action points were recorded on the minutes, alongside an owner and a date to be actioned by. One to one meeting minutes also followed a formal system for recording action points.

The service had a comprehensive audit schedule including clinical audits. The audit results provided assurance and staff acted on the results when needed.

The service had a risk register. Managers maintained oversight of this and staff were able to input into the management of risk, issues and performance. Team meetings included space for escalation of risk concerns.

The service had plans for emergencies, for example, breakdown of scan machine or staff sickness. The Business Continuity Policy outlined actions to take.

Staff had access to the equipment and information technology needed to do their work.

Information governance systems included confidentiality of patient records. Staff understood safe data storage. Secure back-up systems were in place. General Data Protection Regulations (GDPR) had been reviewed to ensure the service was operating within them. The service was careful to ensure confidentiality when using social media for marketing purposes.

The franchise was registered with the Information Commissioner’s Office (ICO) and the registration certificate was clearly displayed.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service worked in close collaboration with NHS services and the local ambulance trust. Managers gave an example of shared learning and working with emergency services regarding potential ectopic pregnancies. This collaborative working facilitated improvements in the timely care and treatment for the patient this scenario requires.

The service engaged with local community groups and stakeholders to understand and respond to the needs of the population it served. This included working with patient groups and, where possible, seeking feedback to shape service development. Staff described efforts to reach underserved or seldom heard groups, with some outreach and partnership working to improve awareness and access to services. The service had a comprehensive planned calendar of health awareness events including cervical cancer, meningitis and septicaemia vaccinations, maternal mental health and PRIDE month.

The provider had a social media platform managed by staff, with oversight from the clinic manager. The team developed innovative approaches to using social media regularly for information sharing including health awareness, pregnancy scans available, appointment availability and pricing.

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 and effective practice.

The service promoted a culture of learning and improvement, with staff demonstrating a clear commitment to developing practice and enhancing patient care. Staff described regular opportunities to reflect on care delivery through team meetings, supervision and informal discussions, and there was evidence that learning was embedded into day to day practice.

Managers supported continuous quality improvement activity and encouraged staff to contribute ideas for change. Staff had an understanding of improvement approaches and were able to describe examples where changes had been implemented to improve patient experience or safety. Managers and staff prioritised quality over profit.

Learning from incidents, complaints and external reviews was used effectively to drive improvement. There were systems in place to review events, identify themes and share learning across the service and the wider franchise group.

The service worked in partnership with a general health scan provider and was proactive in exploring new technologies to enhance people’s experiences.