The York Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last inspection we rated this key question as requires improvement. At this assessment we rated this key question as good. This meant women’s outcomes were consistently good, and people’s feedback confirmed this.

We looked for evidence that women had the best possible outcomes because their needs were assessed. We checked that women’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Women told us staff met all their needs, including managing pain, checking their and their baby’s wellbeing, and ensuring timely review by medical staff.

Women, in the most recent patient survey 2025, said they could get help when needed and they were asked about their mental health.

CQC reviewed 5 sets of electronic notes and found robust assessments of women’s needs at all contact points. Staff clearly documented personalised treatment plans after admission and kept them up to date to reflect identified needs.

Midwifery support workers (MSWs) assessed the needs of women arriving for antenatal clinic appointments. MSWs were able to escalate any concerns to the consultant before the clinic appointment, contributing to safe, well-coordinated care.

Staff discussed risks at daily handover and completed referrals to other services, if required.

The service had a birth outside of guidelines process which was well managed.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Women reported staff supported skin-to-skin contact shortly after birth, following national guidance to promote early bonding and postnatal wellbeing.

Staff were able to describe audits which were ongoing, for example feeding audits and record keeping.

Antenatal care provision was in line with national guidance.

Staff had access to up to date clinical pathways, aligned with national guidance. Key clinical documentation, risk assessment templates and visual prompts were displayed across wards to support consistent practice.

Staff followed a clear maternity escalation policy for deteriorating women and babies to ensure timely assessment and safe decision making.

Specialist midwives, such as safeguarding, quality and patient safety, fetal monitoring, digital and education, were not routinely allocated to clinical work. Their dedicated presence across the service improved visibility and ensured they could focus on delivering specialist expertise and driving service improvement. Staff told us these posts were helpful in the provision of services to women.

Care records consistently demonstrated clear documentation of assessment, evaluation and care planning. Staff assessed and managed pain appropriately in line with national guidance and individual need.

Staff protected the rights of women subject to the Mental Health Act and followed the Code of Practice.

Governance processes were in place to review and update clinical guidelines involving a dedicated lead and staff from all areas.

The service demonstrated effective multidisciplinary (MDT) collaboration with clear evidence of outstanding teamwork and collaboration across all roles and specialities. Staff worked together exceptionally well to benefit patients, supporting one another to deliver safe, high quality, and compassionate care.

We observed excellent communication and coordination between staff of all roles and grades. Women told us staff appeared engaged and happy.

Staff shared patient information promptly and effectively, ensuring continuity of care. Medical and midwifery handovers between wards used structured and detailed MDT communication in a Situation, Background, Action and Result (SBAR) format.

MDT meetings were attended by all specialists, led by the medical team. Staff discussed cases from the labour ward and induction of labour.

Staff spoke positively about the strong culture of teamwork, and collaborative working. Staff told us they felt proud of how well they all worked together. They said there was harmony between doctors and midwives with a clear and visible leadership structure.

Staff told us they were able to have constructive conversations about care.

Community midwives consistently worked in pairs, which supported safety and mutual support in practice.

The appropriate staff attended handovers, midwifery safety huddles and ward rounds. Multidisciplinary input included medical and midwifery staff, anaesthetists and theatre staff.

Most antenatal clinics operated as multidisciplinary clinics, with input from multiple consultants across different specialisms, such as diabetes. Some specialist clinics involved cross site working and collaboration with external trusts, ensuring women had access to the appropriate expertise for their clinical needs.

Safeguarding midwives shared positive examples of partnership working.

Partners told us the service was proactive with a focus on engagement and support for staff across all disciplines. Maternity, neonatal and GP teams worked together to share data across the Yorkshire & Humber Care Record and electronic patient record systems. Personalised Maternity Care Plans were launched in February 2026, co-produced with MNVP, representing a clear improvement in experience and engagement.

The service supported patients to manage their health and wellbeing effectively.

Staff promoted healthy lifestyles and provided practical advice and support.

The service had produced a personalised care plan which included information on a wide range of ways women could lead healthier lives, covering pelvic health and wellbeing, positive lifestyle changes, and support to stop smoking. This helped women make informed choices to control their health and their baby’s wellbeing.

A wide range of health information was available. This included leaflets and posters covering topics such as birth choices, caesarean birth, breastfeeding, smoking cessation, and cord donation.

Myth busting posters addressed common health concerns, including incontinence and breastfeeding, supporting access to clear, evidence based information and promoting health education within the maternity environment.

Staff discussed healthier lives with women at booking and at subsequent antenatal contacts, with all conversations documented on the electronic patients record. This ensured consistent reinforcement of key public health messages and provided a clear record of the support offered throughout pregnancy.

Staff made timely referrals to dietitians and mental health teams when they identified additional needs, ensuring women received targeted specialist support alongside routine health promotion.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Women who used the service had access to their maternity notes via an electronic app. This meant they could access their information in real time. Women could add allergies, their birth plan and feedback about care onto the app.

An extensive audit plan was in place with service, trust and national clinical audits, with an identified lead for each one. The service managed audits electronically with dashboards produced for compliance. The Maternity Audit and Guideline Group oversaw the audit plan, with any escalations made to the Maternity Directorate Meeting with highlights to the trust Clinical Outcomes and Effectiveness Group (COEG).

Staff used the Modified Early Obstetric Warning Score (MEOWS), which is a nationally recognised tool to identify women at risk of deterioration, and escalated concerns appropriately. A New Version of the National MEOWS tool is due to be launched across the trust once staff have completed the relevant training which is planned for September.

CQC reviewed a recent audit completed for MEOWS. Staff undertook all observations on time, and they calculated 90% of them correctly.

The service was no longer an outlier for postpartum haemorrhage (PPH) at 1500ml or more. For March 2025 to March 2026 the average rate of PPH for over 1500mls was 3.8% and within the expected Yorkshire and Humber range of 2% to 4%, and not an outlier compared to other Trusts. A quality improvement project had been completed, and all women now receive a PPH risk assessment at 36 weeks and again on admission to the labour ward.

The service had updated the deteriorating baby standard operating procedure to incorporate the electronic patient record and the implementation of new Newborn Early Warning Track and Trigger (NEWTT2) observation guidelines.

The service reported all Maternal and neonatal deaths through SPEN (Submit a Perinatal Event Notification). This notified Maternity and Newborn Safety Investigations (MNSI), NHS Resolution’s Early Resolution Scheme (NHSR) and Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK). The service investigated all deaths and reported them nationally via the relevant channels. Leaders reviewed and actioned all recommendations via the services governance processes.

The service audited and reported nationally the Antenatal and Newborn Screening performance and Screening Quality Assurance Service (SQAS) performance indicators. Leaders reviewed results at the services governance meetings.

The service had undertaken a health inequalities audit after it missed a target for babies not being brought to hip scan appointments following a positive screening result. It identified scans were only available at York and Scarborough hospitals and not region wide. The audit identified the service did not have enough clinics, did not use text or message reminders, and did not have a formal review process once scans had been undertaken. Leaders shared this with SQAS, and an action plan was in place, reviewed through governance process to increase attendance.

The service participated in the National Maternity and Perinatal Audit Reports (NMPA) audit which identified the service was above the national average for unplanned maternal readmission within 24 days, induction of labour rate and episiotomy rate. Leaders used this information to produce a quality improvement programme for the service.

The service was working towards UNICEF UK Baby Friendly Initiative (BFI) standards but had not yet achieved full accreditation. All maternity staff received Baby Friendly training within six months of commencing employment. Senior leadership received quarterly Baby Friendly assurance reports, and teams regularly reviewed audit findings to identify themes, capture learning, and support continuous quality improvement, while governance forums monitored actions.

The most recent MBRRACE UK report dated March 2026 identified the stabilised and adjusted mortality rates for the service were similar to, or lower than, those seen across similar services.

Staff undertook a quarterly Avoiding Term Admissions Into Neonatal units (ATAIN) audit, which helped the service reduce the number of babies born at 37 and after weeks from needing to go to a neonatal unit. The most recent report showed that the service admitted 3% of these babies to the neonatal unit, which was below the national target level of 6%.

Community leaders told us they completed weekly audits of antenatal bookings from GP surgeries and identified a theme that women were booking later than expected, often at 12 weeks rather than the recommended 10 weeks. They planned to work with GP practices to develop a poster for display in surgeries to encourage earlier booking.

The service monitored compliance with “Fresh eyes,” a structured process where a second midwife independently reviews the cardiotocography (CTG) at defined intervals to provide an additional safety check. The most recent quarterly audit (Q3) showed low performance, with only 26% compliance across 10 cases (seven from York and three from Scarborough), a decline from the previous quarter’s result of 45%. Leaders had implemented fresh eyes improvement work, including reminders for staff to complete documentation correctly using the appropriate form. They recognised the existing audit tool was not effective. Senior leaders reported, if they used a new audit tool (which other trust are moving to), higher compliance of 92%. They developed a SMART action plan to strengthen monitoring, improve data quality, and support sustained compliance.

The service audited BSOTS, with the most recent report (March 2026). Actions identified included allocating a consultant lead, reviewing medical staffing availability against Royal College of Obstetricians and Gynaecologists (RCOG) guidance, implementing the OPEL score and escalation pathway for triage, and undertaking a BSOTS health check.

Digital midwives undertook regular reviews to ensure accuracy, validity and correct use of audit tools. These checks helped the service identify errors, address inconsistencies and close the loop on issues highlighted through clinical audits.

This meant the service had resolved the breach of Regulation 17 (Good Governance) by completing and monitoring the required key environmental and clinical audits, supported by action plans.

Staff supported patients to make informed decisions about their care and treatment and followed national guidance to gain patients' consent.

Women told us they and their family participated in all decision making. Women told us staff provided them with all information required and offered choices according to their needs.

Staff clearly documented consent in care records for all procedures and examinations. Some procedures required written consent and staff uploaded completed consent forms to the electronic patient records. Staff clearly explained the benefits and risks. We observed staff delivering excellent care, using clear consent and effective communication to support women in making the right decisions for both them and baby.

Staff understood how and when to assess whether a woman had the capacity to make decisions about her care. Staff appropriately managed care under the Mental Capacity Act (2005) and completed capacity assessments where they questioned capacity to consent.

Compliance with Mental Capacity Act training was below the Trust target of 90%, with 85% completion for basic awareness training and 60% for higher-level training. The trust advised, once the staffing budget is adjusted in 2027-28 colleagues will have a greater amount of time to support the training requirements associated with their role.