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Archived: Window To The Womb Good

Inspection Summary


Overall summary & rating

Good

Updated 21 May 2019

Window to the Womb in Liverpool is owned by 1st Glimpse Ltd, and operates under a franchise agreement with Window to the Womb (Franchise) Ltd. The service provides diagnostic pregnancy ultrasound services to self-funding women across Merseyside and Cheshire.

We inspected this service using our comprehensive inspection methodology. We carried out a short-notice announced visit to the clinic on 29 January 2019. We gave staff one working days’ notice that we were coming to inspect to ensure the availability of the registered manager and clinic.

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.

The main service provided by this clinic was diagnostic imaging.

Services we rate

We have not previously rated this service. We rated it as Good overall.

We found the following areas of good practice:

  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care. Managers appraised staff’s work performance annually and checked to make sure staff had the right qualifications and professional registration for their roles.

  • Staff assessed risks to women, they kept clear records and asked for support when necessary. Staff kept records of women’s appointments, referrals to NHS services and completed scan consent documents.

  • The service provided care based on national guidance. The service checked to make sure staff followed guidance through local audits, annual clinical audits and peer review.

  • The service controlled infection risk well. The clinic had suitable premises and equipment which met the needs of people who accessed the service. This included people who accompanied women and children.

  • The service made innovative use of technology to provide women with ways to access the service and their scan images. They had developed a mobile phone application which enabled women to document and share weekly images of their pregnancy ‘bump’. They used social media to provide instant information on frequently raised questions and concerns.

  • Window to the Womb had clear governance arrangements that were appropriate to the size and scope of the service. Senior managers from the franchisor actively engaged with managers of 1st Glimpse Ltd and clinic staff. All managers promoted a positive culture that supported and valued staff.

However, we also found the following issues that the service provider needs to improve:

  • Managers could not assure themselves that all staff would identify and respond appropriately to the needs of vulnerable women attending for multiple scans.

  • The service did not have access to translation services for staff to use with women who did not speak English during scan appointments.

Following this inspection, we told the provider that it should make some improvements, even though a regulation had not been breached, to help the service improve.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North)

Inspection areas

Safe

Good

Updated 21 May 2019

We have not previously rated this service. We rated it as

We have not previously rated this service. We rated it as Good because:

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it.

  • Staff understood how to safeguard people from abuse and had completed training at the required level on how to recognise and report abuse. Staff knew how to apply this training.

  • The service controlled infection risk well. Staff kept equipment and the premises clean. They used control measures to prevent the spread of infection.

  • The service had suitable premises and equipment and looked after them well.

  • The service had appropriate arrangements in place to assess and manage risks to women, their babies and families.

  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

  • Staff kept detailed records of women’s appointments, referrals to NHS services and completed scan documents. Records were clear, up-to-date and readily accessible to staff.

  • The service had appropriate processes for staff to raise concerns and report incidents. Staff understood their roles and responsibilities to raise concerns and record safety incidents.

However,

  • Staff we spoke with did not show an understanding of the underlying reasons women may present for multiple scans. This meant there was a risk that they may not identify women with specific needs such as mental health or experiencing abuse and, as such, may not sign post them to appropriate support.

Effective

Updated 21 May 2019

Caring

Good

Updated 21 May 2019

We have not previously rated this service. We rated it as Good because:

  • Staff cared for women and their families with compassion. We saw positive interactions between women and staff. Feedback from women confirmed that staff treated them well and with kindness.

  • Staff provided emotional support to women and their families. The clinic had a dedicated ‘quiet room’ for staff to have sensitive and distressing conversations with women.

  • Staff involved women and those close to them in decisions about their care and treatment.

Responsive

Good

Updated 21 May 2019

We have not previously rated this service. We rated it as Good because:

  • The service planned and provided services in a way that met the range of needs of people accessing the clinic. The facilities and premises met the needs of women and families, including children, that accompanied women to their scan.

  • The service took account of women’s individual needs and delivered care in a way that met these needs.

  • People could access the service when they needed it. The clinic opened on evenings and weekends.

  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.

Well-led

Good

Updated 21 May 2019

We have not previously rated this service. We rated it as Good because:

  • Managers at all levels had the right skills and abilities to run a sustainable service.

  • Window to the Womb had a vision and strategy for what it wanted to achieve and the clinic had a clear business plan to turn this into action.

  • All managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

  • The service systematically improved service quality through regular audits and clinical reviews by lead clinicians employed by Window to the Womb (Franchise) Ltd.

  • The service had systems to identify risks and plan to reduce them. The service completed risk assessments for identified risks

  • The service managed and used information to support its activities, using secure electronic systems.

  • The service engaged well with women, staff and the public to plan and manage appropriate services and collaborated with partner organisations well.

  • The service was committed to improving services by learning from when things went well or wrong and promoting training.

Checks on specific services

Diagnostic imaging

Good

Updated 21 May 2019

The provision of ultrasound scanning services, which is classified under the diagnostic core service, was the only core service provided at Window to the Womb.