You are here

The Original Window To The Womb Good

Inspection Summary


Overall summary & rating

Good

Updated 2 August 2019

The Original Window to the Womb is operated by The Original Window to the Womb Limited. The service is delivered from a baby scan studio in Nottingham four days a week and a satellite studio in Sheffield once or twice a month. The service provides non-diagnostic 2D, 3D and 4D scans, gender identification scans and keepsake images for pregnant women. The service accepts self-referred, self-funded women between the ages of 18 and 45 years of age

We inspected the service using our inspection framework for ‘independent single speciality providers of keepsake/souvenir baby scans using diagnostic ultrasound equipment’.

We inspected this service using our comprehensive inspection methodology. We carried out the short notice announced inspection on 07 June 2019.

To get to the heart of peoples’ 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

Our rating of this service stayed the same. 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 a safe service.
  • The service had adequate well-maintained equipment and the facilities were clean, comfortable and appropriate for the service being delivered.
  • Suitable wellbeing checks were carried out before scans were performed, systems and processes were in place to escalate care in the event of a scan anomaly or medical emergency.
  • Personal information was managed well, records were completed fully and information was stored securely.
  • Procedures were in place to report and investigate incidents, staff were aware of the duty of candour and there was a culture of openness and honesty. ‘How to complain’ information was easily accessible to clients and the public.
  • Scans were carried out in line with evidence-based guidance and recommended standards and the service kept up to date with changes and developments in ultrasound scanning. The service monitored outcomes appropriate to the procedure.
  • The team delivering the service worked well together and understood each other’s roles. Referral pathways had been developed in collaboration with other health services and staff had easy access to other health care professionals if needed.
  • Information was available in different formats so women were able to make informed choices about the type of scan they wanted and any possible risks and side effects.
  • The team were passionate about delivering a positive experience to women and their families. Women and their families were treated in a caring way with dignity and respect. Everyone attending the scan was involved in the experience. Women could contact the provider following the scan if they had any concerns.
  • The service was easy to access, reasonable adjustments had been made so women with a disability and their families could access the service. Information was available in different languages.
  • Appointments were available in the evening and weekends, there was no waiting list or cancellation of appointments.
  • Managers had the skills and abilities to run the service, were visible and were supportive towards staff. They were committed to delivering the vision and values of the service and promoted a positive culture that valued staff.
  • Governance processes reflected the service being delivered, most risks were identified, assessed and managed and plans were in place to manage unplanned emergencies.
  • Managers considered feedback from staff and clients and proactively sought to develop and make improvements to the service.

We found the following areas of outstanding practice:

  • Feedback from women who used the service and those who were close to them was continually positive about the way staff treated them. There was a strong visible person-centred culture, staff were highly motivated and inspired to offer care that was kind and promoted dignity.
  • Women could access the service and appointments in a way and at a time that suited them. Technology was used innovatively to ensure timely access to support and care.

We found the following areas of practice that required improvement:

  • The provider did not have a defined list of mandatory and statutory training.
  • General Data Protection Regulation (GDPR)2018 was not included in the information governance policy.
  • The provider should ensure that electrical wiring in the staff/kitchen room should be housed safely.
  • The provider did not use a practitioner checklist for ultrasound examinations as recommended by the British Medical Ultrasound Society.
  • The provider should ensure that products subject to Control of Substances Hazardous to Health should be stored in a locked cupboard at all times.
  • The service had systems in place to identify risks but they were not always effective. We identified some risks during our inspection and raised these with the provider. The provider took immediate action to eliminate or reduce them.

Following this inspection, we told the provider that it should take some actions, even though a regulation had not been breached, to help the service improve.

Nigel Acheson

Deputy Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 2 August 2019

We rated it as Good because:

  • All staff had mandatory training in key skills.
  • Staff understood how to protect clients 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 well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • The service had suitable premises and equipment and looked after them well.
  • Staff completed and updated risk assessments for each client. They kept clear records and asked for support when necessary.
  • 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 procedure.
  • Staff had access to up-to-date, accurate and comprehensive information about clients’.
  • The service had processes in place for reporting and investigating accidents and incidents.

Effective

Updated 2 August 2019

We rated it as Not rated:

  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Sufficient refreshments were available for clients and their families.
  • Managers monitored the effectiveness of the service and used the findings to improve.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held meetings with them to provide support and monitor the effectiveness of the service.
  • Staff of different kinds worked together as a team to benefit clients.
  • Staff understood how and when to assess whether a woman had the capacity to make decisions about their care.

Caring

Good

Updated 2 August 2019

We rated it as Good because:

  • Staff cared for clients with compassion. Feedback from clients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to women and their families when necessary.
  • Staff involved women and those close to them in decisions making.

Responsive

Good

Updated 2 August 2019

We rated it as Good because:

  • The service planned and provided services in a way that met the needs of local people.
  • The service took account of clients’ individual needs.
  • People could access the service when they needed it.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.

Well-led

Good

Updated 2 August 2019

We rated it as Good because:

  • Managers 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.
  • Managers across the service promoted a positive culture that supported and valued staff.
  • The service improved service quality and safeguarded high standards of care by creating an environment for good.
  • The service had systems in place to identify risks.
  • The service collected, analysed, managed and used information to support all its activities, using secure electronic systems with security safeguards.
  • The service engaged well with clients, staff and the public.
  • The service was committed to improving services by learning from when things went well or wrong, promoting training and innovation.
Checks on specific services

Diagnostic imaging

Good

Updated 2 August 2019

The service was safe, effective, caring, responsive and well led.