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.

This is the first assessment for this service as a diagnostic and screening service. This key question has been rated good.

We found a service that focused on infection, prevention and control. The service had enough staff to meet women’s needs and staff were trained to keep women, and their families safe. The service provided systems and pathways to ensure smooth transitions between providers.

However, we identified breaches in regulation 19- fit and proper persons employed for their sonographer recruitment processes. Staff did not always have the relevant professional registration recommended for their role. Oversight of this was not effective as there were gaps in processes to ensure the right staff was hired for a clinical role.

We have requested an action plan, this will be requested upon publication of the final report.

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.

Staff consistently recognised and reported incidents and near misses, supported by a culture that encouraged the raising of safety concerns. They understood their roles and responsibilities in reporting concerns and documenting safety incidents. Incidents were logged, which enabled effective oversight, action tracking, and monitoring through weekly and monthly meetings. This system also facilitated the identification of recurring themes and trends.

Managers told us that learning from incidents was shared with staff both within the clinic and across the wider service. Lessons learned from other Window to the Womb locations were also disseminated to all staff.

The service recorded very few incidents; we saw 3 entries in the last 12 months from the date of inspection in the accident logbook. A duty of candour policy was in place, and staff described a no-blame culture. They demonstrated a clear understanding of the duty of candour, showing openness and honesty when things went wrong.

All incidents were reported to the clinic manager and documented. Learning was shared through staff information boards, emails, and team meetings.

The clinic had recorded no ‘Never Events’ and no incidences of clinic-acquired infections.

The service had received 1 formal complaint. In response, the clinic reinforced their ‘First Scan’ protocols for not sharing gender predictions prior to 15 weeks due to changes in development which can occur prior to this time. Evidence showed that this change was being actively monitored.

We scored the service as 3. The evidence showed a good standard. 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.

The clinic part of a franchise, the franchise model enabled staff to work across local clinics, supporting flexible opening hours, including evenings and weekends.

People we spoke with reported good communication between the clinic and NHS maternity teams and GP services regarding scan results, referrals, and information sharing. The booking system issued automatic appointment reminders and allowed short notice rebooking in cases such as work or family commitments. We saw evidence that managers followed up with patients who did not attend.

All Window to the Womb locations used consistent systems and communication channels, ensuring sonographers could access support when needed. Patient records were comprehensive, securely stored on an encrypted electronic database, and accessible to all staff. Staff could view records from other clinics, providing insight into previous scans and exposure to ultrasound.

Policies and guidance were in place for managing patient deterioration and urgent referral. All staff were trained in adult resuscitation and basic life support. Staff told us they would follow the emergency action plan and call 999 for hospital transfers. The service had 1 ectopic pregnancy finding emergency transfer in the 12 months prior to inspection. We saw evidence that this was appropriately managed by an urgent hospital transfer via the local ambulance service.

The service used the ‘Paused and Checked’ checklist from the British Medical Ultrasound Society and Society of Radiographers. Sonographers completed checks during scans, confirming identity and consent, providing clear instructions, and explaining results. Women were advised to bring NHS pregnancy notes. Staff ensured women understood that scans were supplementary to routine maternity care and advised those who had missed a 12-week scan to register with a midwife.

All women completed a pre-scan questionnaire, including pregnancy history and a signed declaration confirming NHS care and consent to share medical information if needed. Clear pathways were in place with local NHS providers for referrals when abnormalities were detected. With patients’ consent, staff contacted the relevant NHS unit and arranged appointments.

If an abnormality was found, the sonographer explained findings, and the scan assistant documented the report. Patients were given a copy to take to hospital. In suspected emergencies such as ectopic pregnancies, staff called 999 for ambulance transfer. Staff told us that there was no current arrangement with the local ambulance service. However, staff were trained on how to appropriately convey emergent situations and if needed, and to emphasise the need for a reduced response time.

Daily quality assurance checks were completed on the ultrasound machine to ensure safe operation. A resuscitation trolley was not required due to the nature of the service.

We scored the service as 3. The evidence showed a good standard. 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 registered manager was the designated safeguarding lead. The service had a comprehensive safeguarding policy with clear guidance for identifying and reporting concerns. All staff completed safeguarding training, with 100% compliance at level 3 for both vulnerable adults and children. Training included the Mental Capacity Act and female genital mutilation (FGM), integrated into both adult and children’s safeguarding modules. Staff were aware of safeguarding procedures and the policy and explained how they would refer if concerns were raised.

All staff had Enhanced Disclosure and Barring Service (DBS) checks completed at the start of employment. In the 4 staff files reviewed, DBS checks were documented. The DBS policy acknowledged that circumstances could change after a check was completed; therefore, staff were never left alone with patients, and at least 2 staff members were present during scans.

Staff scanned patients aged 18 and over, and those aged 16–18 if accompanied by a parent. No patients under 16 were scanned. Date of birth was confirmed at booking, and identification was required at the appointment.

Materials from a national domestic violence charity were posted in the toilets. We saw evidence that the service had appropriately shared a safeguarding concern with the relevant Local Authority on the incident log.

We scored the service as 3. The evidence showed a good standard. 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.

Women we spoke to understood they could not have more than 1 scan every 2 weeks and were advised not to attend scans during the 18–21-week window to avoid interference with the NHS 20-week anomaly scan.

Staff were aware of their responsibilities in documenting scan type and frequency and in advising women about the potential risks of ultrasound overexposure. Scanning time was limited to 10 minutes in line with British Medical Ultrasound Society (BMUS) guidelines. Staff adhered to ALARA (As Low As Reasonably Achievable) principles, consistent with the Society and College of Radiographers’ 2017 Guidelines for Professional Ultrasound Practice. Standard operating procedures were visibly displayed in scan rooms for easy reference.

Patients were required to complete online assessments at the point of booking. The information was verified prior to the scan to identify any risks and need. We saw evidence of exclusion criteria written in policy and staff were able to describe these.

3. We scored the service as 3. 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 clinic was spacious and well-lit. All flooring was washable and hygienic. The service had no stairs as it operated from a single level office space on the ground floor. The service had appropriate facilities and sufficient equipment to meet the needs of individuals who attended for scans.

There were systems in place to identify and mitigate risks. We saw evidence of up-to-date risk assessments completed for fire safety, health and safety, hand hygiene, and Control of Substances Hazardous to Health (COSHH).

We saw evidence that staff carried out regular checks of stock, first aid kits, and equipment. Electrical items had undergone safety testing within the previous 12 months, in line with the provider’s safety policy. Managers ensured timely maintenance and servicing of the ultrasound machine. Faults and low stock were reported to the clinic manager through a clear process. All consumables reviewed, including scanning gels, were in date. No faults or concerns were identified during inspection. Clinical waste was stored and disposed of safely under a contract with a third-party provider.

The reception area was clean, secure, and well-maintained. Reception staff maintained a clear line of sight. The waiting area included a television and information leaflets for those attending the clinic.

Personal Protective Equipment (PPE) and hand gels were readily available throughout the premises. Staff completed daily cleaning checks, with signed and dated records observed. Communal areas were clean and well-presented.

The scan room contained a clean, adjustable surgical bed that met recommended standards. A dedicated quiet room was available for sensitive conversations in a private setting. Environmental audits were in place, including evacuation drills. The service had an up-to-date fire risk assessment. Fire extinguishers were in date, accessible and correctly stored, with clear fire exit signage.

People using the service reported no issues with equipment and described the premises as safe, well-maintained, and suitable for their visit.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The registered manager maintained oversight of recruitment, regulatory compliance, and equipment and premises maintenance. The sonographer job description held that all employed sonographers should hold HCPC registration or equivalent and relevant sector qualifications.

On our inspection we observed gaps regarding sonographer registration and professional indemnity aside from the business liability insurance. We raised this with the provider and were subsequently provided with assurance that this member of staff no longer worked at the clinic. Plans had been made to ensure that only sonographers who had the appropriate professional registration worked at the clinic. We were told by senior leaders that improvements had been made regarding recruitment practices by using a third-party agency to verify potential employee details. We have requested for this in writing via an action plan.

However, the service had enough staff to keep people safe. Daily staffing requirements were calculated by the clinic manager and reviewed in advance. People using the service reported satisfaction with staffing levels, and women appreciated the presence of a chaperone at every appointment.

All eligible staff had received annual appraisals, and managers addressed poor performance appropriately. Training was delivered via an online system, tailored to individual roles, and covered mandatory subjects and professional interests. We saw evidence a structured induction process was in place for new staff, including corporate and clinical skills training.

All staff had completed mandatory training in the past 12 months. We saw evidence that training records were up to date. Scan assistants managed enquiries, bookings, supported sonographers during scans, and assisted families with printing scan images. No bank or agency staff were used. Sonographer cover was provided by relocating staff from other clinics within the group.

Ongoing supervision included reflective practice, care discussions, and personal development. Regular team meetings supported communication and service improvement.

Additional opportunities were available for staff, including roles in marketing, telephone support, and bereavement training.

At the time of inspection, the service was fully staffed with no vacancies.

We scored the service as 3. 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.

All areas of the clinic were visibly clean, well-maintained, and appropriately furnished. Handwashing sinks and sanitising gels were readily available, and staff followed hand hygiene protocols and ‘bare below the elbow’ guidance. Personal Protective Equipment (PPE) was accessible and used appropriately. We saw evidence of hand hygiene audits being carried out which showed 100% compliance.

People using the service told us the premises were clean and tidy, with no concerns raised about environmental or equipment cleanliness.

Staff followed the IPC policy, completed mandatory training, and demonstrated strong understanding of IPC risk management. Ultrasound probes were cleaned with sanitising wipes after each scan, and the ultrasound machine was cleaned at the end of each day. We saw recorded evidence of the daily cleaning logs. Transvaginal probes were cleaned with high-level disinfectant foam between uses, and batch numbers were recorded on each patient record form.

Clinical waste was disposed of safely using appropriate bins, which were emptied into external clinical waste containers under a third-party contract.

All areas of the clinic, including high and low surfaces, were found to be clean during our inspection. A dedicated Control of Substances Hazardous to Health (COSHH) cupboard was securely locked, and chemicals were stored in line with legislation.

Blood sampling kits were individually wrapped, centrally ordered, and returned for destruction via a third-party provider. All storage and transportation of samples followed appropriate procedures.

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.