Window to the Womb Also known as Window to the Womb Manchester

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

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 robust systems and pathways to ensure smooth transitions between providers.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff consistently recognised and reported incidents and near misses, supported by a culture that encouraged the raising of safety concerns. They clearly 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 one entry in the last 12 months. 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 zero never events and no incidences of clinic-acquired infections.

One complaint had been received in the past 12 months. In response, the clinic implemented changes in practice: a computer was relocated, and staff were instructed to lock the screen whenever stepping away. Evidence showed that this change was being actively monitored.

Local policies and protocols were up to date and aligned with national guidance. This included standards from the Royal College and Society of Radiographers, the fetal abnormality screening programme, and the British Medical Ultrasound Society.

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 provider’s electronic booking system was monitored daily, with weekly reviews to ensure all necessary information was in place for safe scanning. Women booked appointments online via a 24/7 platform or by calling the clinic directly. The franchise model enabled staff to work across local clinics, supporting flexible opening hours, including evenings and weekends. Clear operational policies guided the booking process.

People we spoke with reported good communication between the clinic and NHS maternity teams 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. Staff maintained confidentiality by locking screens, securing printed materials, and speaking discreetly. We saw evidence that all staff were up to date with mandatory training in record keeping, information governance, and cyber security. The service had a data protection and retention policy aligned with national guidance, and personal data was destroyed accordingly.

Policies were in place for managing patient deterioration. 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. One emergency transfer had occurred in the 12 months prior to inspection.

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; if unavailable, staff contacted the GP or midwife before proceeding. 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 patient consent, staff contacted the relevant NHS unit and arranged appointments.

If an abnormality was found, the sonographer explained findings to the parent(s), and the scan assistant documented the report. Patients were given a copy to take to hospital. In suspected ectopic pregnancies, staff called 999 for ambulance transfer. Staff told us that the ambulance response time was 18 minutes and this target had been achieved for the one hospital transfer that had occurred.

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. A sealed, in-date first aid box was available, and rotas ensured staff with adult and paediatric first aid qualifications were always on duty.

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 service shared concerns quickly and appropriately.

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 vulnerable adults. 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, we saw evidence of this on inspection. In the two 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 two 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. Staff reported rebooking a scan when a patient forgot their ID.

Safeguarding posters and leaflets were displayed throughout the clinic, including materials from a national domestic violence charity in the toilets. No safeguarding incidents had been reported in the 12 months prior to inspection.

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 one scan every two 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.

The service had 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, legionnaires’ disease, and Control of Substances Hazardous to Health (COSHH). Each assessment identified risks, control measures, and the staff member responsible for monitoring. Organisational risks were also documented. Emergency action plans were in place for incidents such as power failure or fire, with clear staff instructions and contact details.

Telephone assessments were conducted to support triage, identify risks and needs, and arrange face-to-face appointments. Staff clearly described exclusion criteria.

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, well-lit, and spread across two floors with bespoke rooms designed by the staff. All flooring was washable and hygienic, with anti-slip surfaces fitted to the stairs. The service had appropriate facilities and sufficient equipment to meet the needs of women.

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. Fire extinguishers were accessible and correctly stored, with clear fire exit signage. 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 disposed of safely under a contract with a third-party provider.

The reception area was clean, secure, and well-maintained, with controlled door access and CCTV coverage. 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 checks on fire extinguishers, fire alarm testing, and evacuation drills. All equipment was labelled with current portable appliance testing, and scanning equipment, including probes, was serviced and calibrated according to manufacturer guidelines.

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 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision, and development. They worked together well to provide safe care that met people’s individual needs.

The service had enough staff to keep people safe. Daily staffing requirements were calculated by the clinical 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.

Recruitment processes included background checks, verification of professional registration, and competency assessments. Clear job descriptions outlined roles and expectations. 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. Some staff were directly employed on zero-hours contracts which they told us suited their other commitments and provided a good work / life balance. 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.

Staff files reviewed were complete, with employment checks and references documented. Induction training and initial assessments for sonographers had been completed.

Ongoing supervision included reflective practice, care discussions, and personal development. Regular team meetings supported communication and service improvement. All sonographers were registered with the Health and Care Professions Council (HCPC), and this was confirmed in the registration log.

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.

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. Staff stated the manager was vigilant about cleanliness, and daily inspections were carried out before scanning lists began. Ultrasound probes were cleaned with sanitising wipes after each scan, and the ultrasound machine was cleaned at the end of each day. 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 inspection. A dedicated COSHH cupboard was securely locked, and chemicals were stored in line with legislation.

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

This quality statement was not applicable as the service does not store, supply, or administer medicines.