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Inspection Summary


Overall summary & rating

Good

Updated 13 May 2019

Window to the Womb Reading is operated by Divinity 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 Berkshire.

The service provides diagnostic imaging for children aged 16 years to 18 years and adults over the age of 18 years. It is registered to provide the regulated activity of diagnostic and screening procedures.

We inspected this service using our comprehensive inspection methodology. We carried out a short notice announced inspection on 5th March 2019. We gave staff two working days’ notice that we were coming to inspect to ensure the availability of the registered manager and clinics.

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.

Services we rate

We have not previously inspected this service. At this inspection 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 understood how to protect patients from abuse and the service worked well with other agencies to do so.

  • The environment was appropriate and met the needs of the range of people who accessed the service including toys for children to play with whilst waiting for parents’ appointments. The service controlled infection risks effectively.

  • Women could access services and appointments in a way and a time that suited them. The service used technology innovatively to ensure women had timely access to ultrasound scans.

  • The service provided care and treatment based on national guidance and could evidence its effectiveness. Managers monitored the effectiveness of care and treatment and used the findings to improve them. The service evaluated images to ensure they were of good quality.

  • The service treated concerns and complaints seriously. The registered manager completed comprehensive investigations and shared lessons learnt with all staff.

  • The service improved service quality and safeguarded high standards of care by creating an environment for good clinical care.

  • Staff were caring, compassionate, kind and engaged well with women and their families.

  • The service took account of patient’s individual needs for example if an early scan showed a miscarriage the women could exit the clinic via another exit rather than passing other waiting pregnant women.

  • Managers promoted a positive culture that supported and valued staff. Staff reported their team worked well together and staff trusted and respected each other.

  • The service collected, analysed, managed and used information to support all its activities, using secure electronic systems with security safeguards.

  • The service effectively managed risks and could cope with both the expected and the unexpected.

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

  • The service’s policy folder detailed an out of date children and adults safeguarding policy from another organisation

  • The service’s children’s safeguarding policy did not reference child sexual exploitation and the staff had not received any training. This was against best practice.

  • The service offered to look after children during scans without completing risk assessments.

Following this inspection, we told the provider that it should make 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

Chief Inspector of Hospitals (London and South)

Inspection areas

Safe

Good

Updated 13 May 2019

Are services safe?

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 protect people from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service controlled infection risk effectively. We observed well-presented staff who kept the equipment and premises clean. They used control measures to prevent the spread of infection.
  • Staff completed and updated risk assessments for each woman through individual referral forms. They kept clear records and asked for support when necessary from the franchise directors.
  • 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 and referrals to NHS services and completed scan consent documents. Records were clear and up to date.
  • 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. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

However:

  • We noted the children’s safeguarding policy did not reference child sexual exploitation (CSE) and staff had not received training in CSE.

Effective

Updated 13 May 2019

Caring

Good

Updated 13 May 2019

Are services caring?

We rated it as Good because:

  • Staff cared for women and their families with compassion. Feedback from women and their partners confirmed that staff treated them well and with kindness

  • Staff provided emotional support to patients to minimise their distress.

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

Responsive

Good

Updated 13 May 2019

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 service took account of patients’ individual needs, it had a proactive approach to understanding individual needs, was accessible and promoted equality.

  • Women could access the service and appointments in a way and at a time that suited them. There were no waiting times for appointments and women could self-refer to the service.

  • The service was currently available four days of the week, open all day Saturday and Sunday and could accommodate same day appointment requests.

The service had a complaints policy and treated concerns and complaints seriously. The registered manager investigated complaints and shared outcomes with all staff.

Well-led

Good

Updated 13 May 2019

We rated it as Good because:

  • Managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care.

  • The service had a vision for what it wanted to achieve and workable plans to turn it into action.

  • Managers across the service 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 and safeguarded high standards of care by creating an environment for good clinical care to flourish.

  • The service had good systems to identify risks, plan to eliminate or reduce them, and cope with both the expected and unexpected.

  • The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.

  • The service engaged well with women, their partners and local organisations to plan and manage appropriate services.

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

However:

  • Staff told us they would offer to look after children during scans, however the service had not performed a risk assessment around the safety of this practice.

Checks on specific services

Diagnostic imaging

Good

Updated 13 May 2019

This is a diagnostic imaging service run by Divinity Ltd as part of the Window to the Womb franchise. The service is based in Reading, Berkshire.

We rated this service as good because it was safe, caring, responsive and well led.  We do not rate effective for this type of service.