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

This means 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 evidence showed a good standard. 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 a clear vision and strategy focused on providing a safe, caring, and supportive service for people using the clinic. The registered manager described their commitment to delivering high-quality care and ensuring people had a positive experience. Staff spoke positively about the service and told us they were proud to work there. We found staff shared the service's values and were committed to supporting people and their families throughout their pregnancy journey.

The service demonstrated a commitment to continuous improvement and innovation. The registered manager told us changes were regularly considered and implemented to enhance the experience of people using the service. For example, the introduction of new 4D technology had improved the range and quality of scans available.

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 registered manager was responsible for two services and divided their time between both locations. Staff told us they were visible, approachable, and available for support when needed. In addition to their presence at each service, the registered manager provided remote support to ensure advice and guidance could be accessed promptly. Staff spoke positively about the support they received and felt comfortable approaching the registered manager with concerns, questions, or suggestions.

The registered manager was also the owner of the business and held overall responsibility for regulatory compliance and the day-to-day oversight of the service. They were responsible for the supervision and appraisal of all staff and demonstrated a commitment to supporting staff development. The registered manager kept up to date with relevant guidance, best practice, and changes within the sector to ensure the service continued to meet expected standards.

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

The service encouraged both people using the service and staff to share feedback, raise concerns, and contribute ideas for improvement. Staff told us they felt comfortable speaking up and were confident that any concerns raised would be listened to and acted upon appropriately. People using the service were also provided with opportunities to give feedback about their experiences, helping to promote an open and transparent culture where views were valued.

We identified that the service's Freedom to Speak Up policy did not include details of external contacts available to staff for raising concerns. The registered manager responded positively to our feedback and took prompt action to update the policy, strengthening the information available to staff.

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

Staff had completed equality and diversity training to help ensure they understood the importance of providing inclusive and non-discriminatory care. Staff demonstrated an awareness of people's individual needs and were committed to treating colleagues and people using the service fairly, with dignity and respect. The service promoted a culture where diversity was valued and people were supported to access services in a way that met their needs.

Staff also told us they were able to work flexibly around their personal and professional commitments, which helped to promote wellbeing and work-life balance. We found evidence of a supportive and inclusive culture, with staff working collaboratively and respectfully towards one another and the people using the service.

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

The registered manager held overall responsibility for governance, quality assurance, and the effective running of the service. Systems were in place to monitor the quality and safety of care, including a programme of local audits, annual audits, and peer reviews. Patient records, including paper and electronic information, were stored securely, and electronic systems were protected to help maintain confidentiality and protect personal information.

The service used monitoring and audit processes to identify areas for improvement and support continuous development. During the inspection, we identified an issue relating to the oversight of cleaning records, as these did not fully reflect the condition of some areas within the environment. We shared this feedback with the registered manager, who responded promptly and took immediate action to address the concerns and strengthen the oversight of cleaning and monitoring processes. This demonstrated a proactive approach to improving the quality and safety of the service.

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

The service had a clear and documented referral pathway to ensure people could access appropriate support and treatment when required. Staff understood the importance of working in partnership with other healthcare providers and services to promote continuity of care. Where a need was identified that could not be met by the service, referrals were made in a structured and timely manner, with appropriate records maintained to support safe and effective care.

The service demonstrated an understanding of its responsibility to collaborate with other organisations so that services worked seamlessly for people. Staff were able to signpost and refer women to relevant healthcare providers and support services when required. Feedback from people using the service was positive, with women commenting favourably on their experiences and the support they received throughout their care journey. The service actively supported charitable and community initiatives through fundraising activities, sponsorship, and participation in local events.

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 contribute to safe, effective practice and research.

The registered manager demonstrated a strong commitment to learning, improvement, and delivering a high-quality service. Throughout the inspection, they responded positively to feedback and took prompt action to address issues identified. This proactive approach supported continuous improvement and showed a willingness to make changes where necessary to enhance the safety and quality of the service. The registered manager was passionate about the care provided and was focused on ensuring people had a positive experience.

The service actively sought feedback from women to help identify opportunities for learning and development. Women were encouraged to share their experiences through online review platforms and social media channels, enabling the service to understand what was working well and where improvements could be made. Feedback was valued and used to support ongoing improvements and innovation within the service.