Window To The Womb Stoke

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• 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 safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. Leaders had systems for identifying and responding to deteriorating women in the department. Women received treatment and care to reduce the risk of avoidable harm.

There were safety processes arranged before procedures started, with staff working together to ensure the right patient had the correct imaging. Women were safe from neglect, abuse, and discrimination. They gave informed consent prior to procedures.

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 evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. Staff and leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Learning was shared with staff.

The service had a current incident reporting policy in place. There had not been any reportable incidents. We looked at the electronic system for managing incidents and saw staff had reported that a person had not been happy with the photographs they had received, leaders had investigated, apologised and refunded them. There had not been any repeated themes or trends in the year prior to our assessment.

Staff were able to identify and report risks, secure in the knowledge these would be addressed. Where there was an immediate risk of harm, staff felt confident to intervene to prevent harms occurring. Staff were able to give examples of how they had handled such situations in the past, for example, if an anomaly was found during a scan.

Staff received feedback from investigation of incidents in team meetings. Staff were able to discuss the recorded incident with us.

The service provided mandatory training in key skills to all staff, and all staff had completed it. Managers monitored mandatory training and alerted staff when they needed to complete updates. Managers used appraisals to identify gaps in learning. Staff had completed the nationally recognised training in supporting people with learning disabilities and autism. There was a current mandatory training policy. Staff told us they had been able to complete some of their mandatory training at home for which they got paid.

Some staff did not fully understand the concept of duty of candour. We raised this with the nominated individual during the inspection and following the inspection, leaders reissued the duty of candour policy to all staff to review and sign and as well as adding the topic to the next team meeting agenda in April. There was a duty of candour policy.

The evidence showed a good standard. The service worked with women 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 women moved between different services.

Safety and continuity of care was a priority throughout women’s care pathways. Women attending for a scan were asked to fill in an in-depth pre-scan questionnaire prior to booking. The questionnaire included various relevant questions such as cycle length, whether they had a previous scan, as well as other medical history. If they had not done this prior to arrival, they could do this on a tablet in the clinic.

Suitably skilled and qualified staff accompanied women in all areas and undertook the required procedure. Care records were electronic and were kept securely. The IT connectivity was consistently available across the service to meet the needs of staff completing the records. Staff completed first aid training.

When overall responsibility for the care and treatment of a person moved to a different service provider, such as transfer to the NHS, there was effective communication, which allowed for seamless transfer.

he evidence showed a good standard. The service worked with women and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving women’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.

Staff understood how to protect women from abuse and the service worked well with other agencies to do so. Staff received adult and children's safeguarding training appropriate for the role they provided, for example we saw the sonographer had completed their safeguarding adult and children's level 3. There were current safeguarding policies, which reflected the national guidance for adults and children.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. The registered manager had oversight of safeguarding within the service. We heard of an example where the registered manager had made a safeguarding referral to the local authority and the police to ensure the person’s safety.

Young people aged 16 to 18 needed to have the consent of their parents to undergo a scan. If a child under 16 presented, the team would refer to the local authority safeguarding team. If under 18, staff requested to see a full birth certificate and photographic identification.

The service had an up-to-date chaperone policy, which women were informed of when they attended the service. We observed that chaperones were available for every scan that took place. The staff notice board contained a safeguarding flowchart and useful contacts for safeguarding organisations. We saw posters in the toilet displaying information on domestic violence.

The evidence showed a good standard. The service worked with women to understand and manage risks by thinking holistically. Staff provided care to meet women’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service worked with women to understand and manage risks. The treatment and care met their needs in a way which was safe and supportive, and staff advised women to attend all their antenatal appointments.

Information involving risk was readily available such as what to expect when situations arose such as inconclusive scans, missed miscarriage, pregnancy of an unknown location and complete miscarriage. We also saw an information leaflet on sub-chorionic bleed. Such information was available on the Window To The Womb website or in a pack that was provided to women when they attended the clinic. There was a detailed referral flowchart for inconclusive findings and emergencies.

The information pack provided to women also contained a list of contacts for local NHS hospitals for early pregnancy including early pregnancy assessment unit and out of hours gynaecology services. It advised women if they could not get through to the numbers to speak to someone to go to the emergency department and take the scan report and referral letter with them. Information leaflets were clear that women should contact their GP if they needed further advice.

Staff were aware of the protocols of what to do in an emergency such as calling an ambulance if an ectopic pregnancy was found. We noted there was an emergency folder in situ. The folder contained identified risk assessments such as fire safety, fire drills and evacuation logs, the emergency policy for managing emergencies such as ectopic pregnancy diagnosis and obstetric emergencies. It also contained details of ambulance services and fire alarm tests which were up to date.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The design, maintenance and use of facilities, premises and equipment kept women safe. Staff were trained to use equipment.

There were safety measures for staff to contact the emergency services directly if a situation arose around security. The building also had a panic alarm, and closed-circuit television. We saw there was a clinic security policy.

There was suitable equipment provided and used correctly. All portable electronic appliances had been tested for safety in January 2026. The scanning machine was brand new so was not due yet for its annual inspection and was still within its warranty period.

Leaders told us they reviewed building risk assessments annually. If there were any updates in between, they revisited them. They advised everything was flagged electronically which meant areas could not be missed.

Staff disposed of clinical waste safely, both inside and outside the building in a locked bin. A business waste company collected the bins on a weekly basis. Hazardous substances were stored safely. There was a control of substances hazardous to health file. Audits on appropriate storage of substances found compliance was fully achieved.

At the time of the inspection, building works were being carried out next to the building impacting on the car parking area. Leaders identified this as a potential risk but told us they were in regular contact with the site manager, had the car park swept regularly and were mopping the clinic floors more regularly.

The evidence showed an exceptional standard. The service made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

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

Staff included a nominated individual, registered manager, 2 sonographers, a team leader, and scanning assistants. The service did not have any vacancies; however, we learnt that the registered manager was shortly leaving the service after several years. The plan was for the nominated individual to take over the registered manager role as they had previously been in the post and knew the service well.

New staff had a full induction tailored to their role before they started work. We saw induction checklists on staff files which included areas such as safeguarding, care and wellbeing, core policies, and control of substances hazardous to health.

Leaders supported staff to develop through constructive, recorded annual appraisals and constructive supervision of their work. The senior sonographer and service manager signed off any new sonographers before they could scan alone. The senior sonographer did supervised sessions with other sonographers at the Stoke site and other sites monthly. Sonographers also met every 2 months to discuss any special cases and share learning.

The sonographer demonstrated good clinical knowledge, used appropriate terms to describe findings and reports were detailed.

Staff said they were able to take breaks during their shift. Women felt their needs were met in a timely way and we observed staff attended to them in a kind and supportive way. Women appeared comfortable and were engaged in conversations because there were sufficient staff.

The service supported the learning and development needs of staff and made sure staff received any specialist training for their role. Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge. For example, we were provided with a schedule of upcoming training sessions for 2026 which was to be delivered by the clinical governance panel. Subjects included early pregnancy training and gynae training for scan assistants, molar pregnancy, image optimisation and 4D techniques and ovarian cysts and corpus luteal cysts amongst others.

Managers made sure staff attended team meetings or had access to the information shared when they could not attend. We saw general information was available shared on notice boards.

The evidence showed a good standard. 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.

The service managed infection risks well. Staff used equipment and control measures to protect women, themselves, and others from infection. They kept equipment and the premises visibly clean.

The department was visibly clean, free from clutter and had suitable furnishings which were clean and well-maintained. Hand gel was readily available in the waiting area and scanning room.

There was a provider infection prevention and control policy and supporting guidance that was accessible to staff. The policy contained guidance for staff in areas such as waste management, sharps disposal and hand hygiene.

Leaders completed regular audits in which they performed well. Audits included uniform standards, scanning machine cleanliness, and probe storage, scan machine cleaning logs.

Staff cleaned equipment after patient contact. Deep cleaning log checklists showed monthly deep cleans of the clinic including toilets, scanning room, reception areas as well as toilets in addition to daily cleaning checklists. There were also scanning machine cleaning logs.

Staff followed infection control principles including handwashing and the use of personal protective equipment (PPE). Staff notice boards had information for staff on donning and doffing PPE.

There were clinical waste bins available with yellow bags, and waste was disposed of appropriately. Sharps bins were available to staff and were collected by an external company every 2 weeks.

Women we spoke with felt the clinic was clean and tidy during their visit. We saw the sonographer wearing and changing their PPE as well as washing their hands. Staff disposed of PPE appropriately and wiped the clinical areas down between appointments. There were appropriate hand-washing facilities in the scanning room.

Staff supported infection prevention and control measures by following the uniform policy. Staff in clinical areas were arms bare below their elbows to allow for full hand decontamination.

We did not look at Medicines optimisation during this assessment. There is no previous rating for the Safe key question so we cannot yet publish a score for this area.