Window to the Womb

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• 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.

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

We scored the service as 3. 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.

Staff consistently reported high levels of motivation and positivity about their roles. They described a culture that was friendly, safety-focused, and open, and stated they received strong support from managers. Teamwork was described as effective, and the working environment as encouraging.

Staff spoke of an open and honest culture within the service and were overwhelmingly positive about their experiences. One staff member told us: “I love my job here, we are a really good team”, another said “It is not only about the scan, but we create an experience for women and their families when they see their babies for the first time”.

Although the service did not have its own set of values, staff demonstrated alignment with the ethos of the Window to the Womb franchise.

During the inspection, visible leadership was observed. Managers engaged readily with women and those accompanying them. They demonstrated a clear understanding of service-specific and wider sector challenges and priorities. Staff reported that leaders ensured managers were equipped with the necessary skills, training, and experience to fulfil their roles. Bespoke training was provided by the franchise to support this.

There was a systematic approach to monitoring and reviewing progress against strategic plans. These plans were consistently implemented and had a positive impact on service quality and sustainability. The registered manager articulated the franchise strategy and future plans clearly, including defined objectives for growth and sustainability. The clinic manager demonstrated commitment to achieving the best outcomes for women, and the service vision had been developed collaboratively with service users and external partners.

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

Staff spoke highly of both the registered manager and clinic manager, describing them as approachable and supportive. They reported feeling valued and comfortable raising concerns. Staff stated that managers supported their career development and promoted a healthy work/life balance.

The service did not have a FPPR Policy due to the nature and size of the service. However, peer assessments, service and care and clinical lead reviews were carried out.

Managers at all levels were described as having the appropriate skills, experience, and abilities to lead a sustainable service. Staff, including scan assistants, reported that company directors and the area manager were visible and approachable, visiting the clinic periodically to conduct audits and engage with staff.

Leadership development was embedded within the service, supported by a clearly defined leadership structure. All senior managers had been with the franchise in various capacities for over 10 years. The clinic manager led the Window to the Womb clinic operationally and was responsible for day-to-day service delivery. Staff reported that this structure worked well.

Senior staff provided support across all clinics nationally and demonstrated flexibility and continuity in their approach. Staff expressed pride in working for the organisation and spoke positively about the culture. During the inspection, staff were observed to be friendly, confident, and welcoming. They expressed pride in their roles and in the quality of care provided. Staff morale was positive, and women using the service described staff as consistently friendly and helpful.

We scored the service as 3. 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 maintained an open culture that encouraged staff to raise concerns without fear of reprisal. This was supported by clear policies and accessible leadership. Staff reported feeling confident in raising issues should these occur.

A Freedom to Speak Up (FTSU) policy and guardian were in place and accessible to all staff. The policy outlined the process for speaking up and what staff could expect in return, promoting transparency and support.

Staff stated they could approach managers with concerns and described the management team as having an “open door” approach.

An equal opportunities policy was in place to support fair decision-making and prevent discrimination. It addressed both direct and indirect discrimination.

We scored the service as 3. The evidence showed a good standard. The service cared about and promoted the wellbeing of their staff and supported and enabled staff to always deliver person-centred care.

Staff told us their wellbeing was prioritised to support high-quality care. The service fostered a supportive and inclusive environment, with staff reporting they felt valued and encouraged to contribute to service improvements. One staff member said, “We are a good team made up of younger and older staff and a mix of different life experiences. Everyone welcomes each other’s perspective.”

Emotional support for staff was embedded in the service. Staff had access to an external agency offering support across financial, legal, and therapeutic topics. The registered manager conducted informal wellbeing check ins within the team and provided staff with a wellbeing survey.

Staff described manageable workloads and a collaborative team culture. Training and support were discussed weekly, and daily handovers included team briefs and shared learning. We saw evidence that staff received regular appraisals and ongoing communication from managers via multiple channels.

Staff reported a good work/life balance and felt able to raise wellbeing concerns with colleagues and managers. They also told us that directors encouraged innovation and new ideas.

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

Staff told us they attended regular monthly team meetings, which were scheduled to ensure full participation. Meeting minutes were made available, keeping staff informed of actions and updates. We saw evidence of formal meeting notes and actions from clinical governance meetings.

The clinic manager demonstrated a clear understanding of service-related risks and met regularly with the registered and area manager to review performance.

Governance arrangements were regularly reviewed and reflected best practice. The provider adopted a systematic approach to working with external organisations to improve care outcomes and ensured policies aligned with national guidance and emerging sector standards.

The registered manager held overall responsibility for clinical governance, supported by franchise directors. The governance framework enabled staff to deliver safe and effective care and was tailored to the nature of the service. Senior leaders held designated roles, including safeguarding leads and policy oversight.

Policies were clearly indexed, comprehensive, and accessible to staff. Training files were maintained in digital format and audited. Governance systems were overseen by the franchiser, who conducted a full catalogue of audits.

We scored the service as 3. The evidence showed a good standard. 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 engaged with people through informal interactions, patient surveys, and feedback forms.

Staff emphasised the importance of delivering high-quality services for women alongside NHS provision. The registered manager described strong relationships with the local NHS Trust colleagues and outlined potential for future collaboration to support NHS services.

The provider’s social media platform was centrally managed, with oversight from the clinic manager. The team developed innovative approaches to using social media for information sharing.

We spoke to local NHS GP partners whose patients often used the clinic for pregnancy or general health related ultrasound scans. These partners found the reports were detailed and of a good standard. However, some reports included a large amount of additional health information that was not directly related to the scan findings.

The service worked in partnership with FirstScan and was proactive in exploring new technologies to enhance women’s experiences. The service had a Use of artificial intelligence (AI) policy which outlined appropriate use of AI within the clinic to improve administrative efficiency and provided a list of franchise approved AI tools for those purposes.

The service also used a General Data Protection Regulation (GDPR) compliant business specific chat platform for collaboration between staff from clinics within a region.

Staff demonstrated a strong commitment to continuous learning and service improvement.