Window to the Womb, is operated by Devon Ultrasound Limited and operates under a franchise agreement with Window to The Womb (Franchise) Limited. They provide obstetric ultrasound services for pregnant women from 16 years of age, scanning from six weeks to full term. The service is provided to self-funding women across Devon.
The service provided the single specialty core service diagnostic imaging. We inspected this service using our comprehensive inspection methodology. We carried out a short notice announced inspection on 22 May 2019.
To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.
Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.
This was our first inspection of the service since the service opened in November 2016. We rated it as Good overall.
We found the following areas of good practice:
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A safe service was provided. Staff had the right qualifications and skills, received and completed mandatory training, and understood how to protect people from abuse and report incidents.
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The service had a suitable environment and equipment available and infection risk was well controlled.
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Detailed records of women’s care and treatment were completed, with risks assessed and clear referral pathways if a scan identified a concern or anomaly.
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An effective service was delivered based on national guidance, mental capacity and consent legislation, and improvements were made where needed.
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Staff were inducted and ensured competent in their role, to include relevant registration with the Health Care Professional Council. Staff worked well together and with other healthcare providers.
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A high level of care was provided within the service. Staff cared for women and those close to them with compassion, kindness, dignity and respect. People were truly respected and valued as individuals.
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Staff provided emotional support to women and those close to them to minimise their distress. Emotional and social needs were highly valued by staff and embedded in care and treatment.
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Staff involved women and those close to them in decisions and their care and treatment. Their individual preferences and needs were reflected in the care delivered.
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The service was responsive to the needs of women and their families, and was tailored to pregnant women. People were able to access an appointment when they needed it.
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Concerns and complaints were investigated and lessons were learned and shared with all staff.
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The service was well-led with strong local leadership, and a positive culture was promoted and present amongst staff. The service engaged with women and their families, and staff, to help plan and manage the service.
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The service systematically improved service quality and safeguarded high standards of care. There were systems to identify risks, and plan to eliminate or reduce them.
However, we found some areas which could be improved:
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A limited level of health promotion was considered or shared with women using the service. Instead, women would receive their health promotion via the NHS maternity pathways and care.
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Some staff files did not contain two proof of identity documents, with photo and address. The registered manager was rectifying this following our inspection.
Following our inspection, we told the provider that is should make a few improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.
Dr Nigel Acheson
Deputy Chief Inspector of Hospitals