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

This means we looked for evidence that people were protected from abuse and avoidable harm.

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.

There had been no incidents or accidents in the last 12 months. Staff and the registered manager were able to clearly explain the procedures they would follow should an incident occur, including ensuring people were kept safe, reporting concerns appropriately, and taking immediate action where required. Staff told us that any incidents would be fully documented and reviewed. The registered manager explained how records would be used to identify patterns, themes, and areas for improvement, and understood the importance of sharing learning with the staff team to reduce the risk of similar events occurring in the future.

The registered manager demonstrated a commitment to continuous improvement and fostering a positive learning culture. Changes had been implemented following our last inspection to improve the service.

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.

There were clear policies and procedures in place to guide staff on when referrals should be made and how to respond in emergency situations. Staff demonstrated an understanding of these processes, and we saw evidence that appropriate referrals had been made when people required additional support or specialist services. The service recognised its responsibilities for safeguarding people and ensuring they could access the right care and treatment when needed.

The service had a clear booking and assessment process which captured relevant information about people's needs prior to appointments. Appointments could be arranged either by telephone or online, helping to ensure the service was accessible. Information provided by the service clearly stated that it was a diagnostic service. Staff understood the limitations of the service and were able to explain how people would be referred to other healthcare professionals or services where further assessment, diagnosis, or treatment was required.

The service worked with people and healthcare partners to understand what being safe meant 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.

There were no open safeguarding concerns at the time of our inspection. The registered manager demonstrated an understanding of their responsibilities for safeguarding people and told us that where they had suspected abuse, concerns had been reported promptly to the relevant local authority for investigation. Records showed appropriate action had been taken to protect people and ensure concerns were escalated in line with local safeguarding procedures.

Staff were knowledgeable about safeguarding and were able to describe the different types of abuse they may encounter, including physical, emotional, financial, and neglect. They understood the signs to look out for and were confident in explaining how they would respond to concerns and report them appropriately. We saw evidence that all staff had completed safeguarding adults and safeguarding children training, which helped ensure they had the knowledge and skills to protect people from harm and abuse.

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

The service had systems in place to identify and manage risks to people using the service. Information gathered through the booking process enabled staff to capture relevant details and identify any risks that required further assessment or action before appointments took place. Staff used this information to ensure people received appropriate support and were referred to other services where necessary.

There was a clear policy in place for making referrals to the Early Pregnancy Unit when concerns were identified. We saw evidence that referrals had been made appropriately and in a timely manner. The sonographer involved people in managing risks by fully explaining procedures, discussing findings, and ensuring people understood any next steps. This helped people to make informed decisions about their care and treatment.

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 service maintained a safe and welcoming environment for people using the service. Staff disposed of clinical waste safely. Appropriate equipment was available to support the delivery of care and treatment, and records showed that equipment was regularly checked and maintained to ensure it remained safe for use. The service also had suitable facilities to accommodate people’s family members and friends when required. The lounge area was spacious, well‑furnished and comfortable, offering a welcoming environment that supported a positive experience for people using the service. A private and quiet space was available for people who wished to discuss sensitive matters, ask questions, or take time away from the main waiting area when needed.

During the inspection, we identified that needles were not being stored securely. The registered manager responded immediately to this concern and took prompt action to address the issue, reducing the risk of harm to people and staff.

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 staffing team consisted of a registered manager, sonographers, scan assistants, a shift leader, and a phlebotomist. The registered manager told us staffing levels were planned to meet the needs of the service and were reviewed regularly to ensure people could access appointments when required. They explained that the service was able to accommodate early morning or later appointments where requested, helping to meet people's individual needs and preferences.

The registered manager told us there were planned changes to the staffing structure; however, recruitment was underway to ensure this did not impact the delivery of care and treatment. Staff had completed training relevant to their roles and demonstrated the skills and knowledge required to carry out their responsibilities safely. New staff completed an induction within the first few weeks of employment, which helped ensure they understood their role, the service's policies and procedures, and how to provide safe and effective care.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

During the inspection, we identified some environmental and cleaning concerns that required attention. These findings were not reflected in the service’s cleaning records. We raised our concerns with the registered manager during the site visit, who took prompt action to address the issues identified and updated cleaning and monitoring processes accordingly. This demonstrated a willingness to respond to concerns and make improvements to support a safe environment for people using the service.

Staff understood and followed infection prevention and control (IPC) principles, including effective hand hygiene practices. Personal protective equipment (PPE) was readily available, and staff were observed using this appropriately to help reduce the risk of infection and protect people using the service.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

The service did not store, prescribe, administer, or supply medicines. However, the service carried out blood tests as part of the care and treatment provided. Appropriate procedures were in place to support these activities and ensure they were undertaken safely and in line with the service's policies.

Staff involved in carrying out blood tests had received relevant training and demonstrated an understanding of their roles and responsibilities.