The York Hospital

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

At our last inspection we rated this key question as inadequate. At this assessment we rated this key question as good. This meant women were safe and protected from avoidable harm.

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that women were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination.

The service was in breach of Regulation 12 (safe care and treatment), and Regulation 15 (premises and equipment), and Regulation 18 (Staffing).

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.

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.

The service reviewed safety events effectively, with clear actions identified and learning shared through established feedback mechanisms. These changes addressed the concerns from the previous inspection, ensured timely oversight, consistent scrutiny of clinical care and a proactive approach to identifying learning and strengthening safety. This resolved the breach of Regulation 17 (good governance).

Staff and leaders maintained daily oversight of all maternity safety events. They triaged cases for ward level review or escalated them to a three-weekly maternity case review meeting, where they discussed moderate harm or notable safety events.

The Maternity Assurance Group monitored safety event data, harm levels and learning responses, providing robust local oversight, with further escalation into trust wide governance forums where required.

Staff felt empowered to report safety events and described increased confidence in doing so. They described a strong learning culture and provided examples of how they had changed practice and updated guidance following safety events. Staff understood what to report and had received Patient Safety Incident Response Framework (PSIRF) training.

The Professional Midwifery Advocates (PMAs) supported staff with regular feedback and hot debriefs which provided real‑time reflections following safety events to identify immediate learning, support staff wellbeing and strengthen the wider learning culture.

Learning from safety events, reviews, complaints and concerns was shared through a range of communication channels, including weekly bulletin updates, patient‑safety briefings delivered at every handover and huddle, and short SNAaK (Safety, News, Action and Knowledge) bites with clear, concise messages which reinforced key safety priorities and supported continuous improvement in line with learning‑culture expectations.

Leaders shared learning from avoiding term neonatal admission to the neonatal unit (ATAIN) reviews through dedicated newsletters, and staff held weekly ATAIN meetings.

Quality and safety midwives collaborated closely with women and their families throughout the safety event process, ensuring their voices informed reviews, actions and service improvements. Women were offered debriefs and copies of incident reports in line with involving‑people expectations.

Staff demonstrated understanding and compliance with the duty of candour principles, ensuring openness and honesty when safety events occurred. Leaders audited duty of candour and presented the audit findings at the Patient Safety and Clinical Effectiveness Committee.

Partners described an inclusive approach to patient safety where issues were shared and discussed. They described an open and honest culture for staff and women/family members involved and a collaborative approach with all external partners.

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.

Women reported they had the same community midwife throughout their pregnancy and most women said they could easily contact them.

Staff held a daily huddle where all departments came together to review staffing arrangements, home birth plans, planned caesarean sections, delays in service provision, baby tagging, transfer of patients, review potential discharges and Operational Pressures Escalation Levels (OPEL) status. This ensured staff and leaders were aware of any issues across the whole pathway and could provide support.

A dedicated team worked in the triage area. They followed a standard operating procedure (SOP), to support patient safety through rapid assessment, prioritisation, and appropriate escalation. Leaders had identified the need for a lead consultant to provide consistent clinical oversight and standardised decision making to strengthening the triage pathway and improving responsiveness.

Staff undertook telephone triage following the Birmingham Symptom Specific Obstetric Triage System (BSOTS) to support women antenatally and postnatally. The service audited the calls and reported the results into the maternity directorate meeting. Staff recorded 92.35% compliance with rapid assessment at triage within 15 mins in Feb 2026.

We observed multiple triage reviews, including telephone and face to face assessments, with appropriate reviews undertaken, such as scans and clinical assessments by medical and Midwifery teams.

All women were risk assessed during the triage process; this meant the service was no longer in breach of Regulation 12 (Safe care and treatment).

Staff told us the induction of labour process was good with very few occasions where there was not enough capacity to meet demand.

Staff could describe the process to follow to ensure safe transfer of mother and baby from labour ward to postnatal ward.

Staff and leaders held weekly meetings to review and coordinate elective caesarean section activity. Leaders said this enabled proactive management of any additional lists and ensured very few theatre list postponements. They worked collaboratively with other hospitals to support women when capacity was an issue.

Two theatres were available within the labour ward to manage emergency and elective workload. Staff undertook the correct checklists and risk assessments.

The service shared women’s electronic records with primary care and health visitors to support continuity of care. The service ensured correspondence was sent via mail for those women who lived out of area.

New consultants worked across both sites to ensure departments shared best systems and processes.

The maternity unit did not have a post anaesthetic care unit (PACU) located in a dedicated area outside the operating theatre to ensure safe observation. This meant the service did not meet the Association of Anaesthetists guidelines (2013), which stated staff should recover all patients in a specially designated area after general, epidural, or spinal anaesthesia. There were future plans to refurbish an area to create a separate recovery space for PACU by 1st June 2026.

Staff security tagged babies to prevent them being removed undetected. This meant the service was no longer in breach of Regulation 12 (Safe care and treatment).

Staff were familiar with the baby abduction process, and the tagging procedures used to keep newborns safe. They described an effective system for securing the ward in the event of a lockdown, with clear actions and responsibilities to ensure the environment remained safe and controlled. The service conducted baby abduction drills annually.

The community midwives provided a homebirth service. Staff and leaders helped produce a home birth guideline which incorporated guidance for women who choose to deliver at home outside of standard care guidelines. Leaders reviewed compliance of all booked home births monthly with a report on all home birth activity presented at Maternity Assurance Group.

Community staff participated in an on-call rota to support the hospital service when it was short-staffed, providing on call cover for 8 hours, which ensured they did not breach working time directives.

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.

Staff demonstrated a good understanding of safeguarding procedures and were confident in raising alerts. They routinely assessed women at every contact for changes in psychological or emotional wellbeing and checked for any safeguarding risks.

Care records showed appropriate documentation, with concerns recorded on the electronic patient record, which generated clear flags and alerts to support follow up. This included any instances of female genital mutilation (FGM), an illegal practice in the United Kingdom.

Safeguarding midwives shared learning from the HALO Trust, a specialist organisation supporting victims of FGM, forced marriage and honour based abuse, who delivered training to staff on recognising and responding to these forms of harm. This supported staff awareness, confidence and multi-agency working in line with FGM safeguarding expectations.

Staff gave clear examples of the process they had followed to escalated concerns. Staff understood who to inform and followed the correct escalation routes, ensuring prompt action when risks were identified.

Midwives had access to safeguarding advice and guidance 24 hours a day, seven days a week, with out of hours support from local authority emergency duty teams and senior clinical oversight from two named doctors for safeguarding children.

Staff used learning from recent rapid reviews to inform training, helping them develop their skills, reflect on practice, and maintain confidence in managing safeguarding concerns.

Women and families received support throughout the safeguarding process. Staff provided women and families debriefs and copies of safeguarding reports.

The service shared with staff a quarterly safeguarding newsletter celebrating good practice and recognising “Safeguarding Stars.”

All safeguarding policies were clear and comprehensive.

Safeguarding training in adult and children level 1, and children level 2 exceeded the trust target of 90%. Adult safeguarding level 2 and children’s safeguarding level 3 were close to target; however, compliance for children’s safeguarding level 3 remained low at 65%.

Mental Capacity Act basic awareness training met 85%, while higher level Mental Capacity Act and DoLS training was significantly lower at 60%, indicating further improvement was required in line with safeguarding training expectations.

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 told us staff had provided clear information and advice about their care and treatment in a way they understood.

The service received women’s feedback through collaborative working with the Maternity and Neonatal Voices Partnership (MNVP), as well as the national patient survey.

We observed regular, effective handover meetings, huddles and ward rounds. These were attended by all relevant staff, who were able to share information and escalate concerns. Leaders reviewed staffing every 4 hours to ensure departments were safe.

Staff demonstrated good practice in identifying and monitoring risks and escalating them when required. Care records showed no gaps in completed risk assessments. Identified risks were clearly recorded, supporting ongoing oversight of concerns such as mental health needs, allergies and relevant antenatal indicators which increased clinical risk.

Staff routinely discussed key information to maintain safety, drawing on holistic assessments that considered clinical observations, obstetric risk factors, safeguarding concerns and wider wellbeing needs. This supported staff to involve women in decisions about their care and to manage risk proactively.

The service undertook Maternity Case Reviews (MCRs), structured reviews of individual maternity cases, to review clinical care, identify learning and monitor whether risks were recognised and escalated appropriately.

The service had two specialist midwives who supported women experiencing social complexity. Staff used a Maternity Disadvantage Assessment Tool (MatDAT) to identify women experiencing social complexity to tackle high levels of maternity disadvantage and improve equity in care, particularly for marginalized groups.

Staff described strong support from medical staff and specialist teams such as the tissue viability nurses.

There was always a consultant obstetrician and anaesthetist medical doctor on call for any obstetric emergencies.

Security was good in all areas. Women had access to call bells.

The trust does not currently provide transitional care; however, staff were developing a strategy, and the trust has recently appointed a Transitional Care Lead.

Partners told us the trust supported additional funding for MNVP leads which ensured a comprehensive view of service user need, with a workplan in place to expand to engage with all community groups.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

A Patient Led Assessments of the Care Environment (PLACE) review was undertaken in 2025. It did not find any environmental concerns. CQC have received no concerns from patients regarding the maternity environment.

Leaders told us about challenges with the physical estate and acknowledged the maternity unit did not meet current building standards for maternity services, and accessibility remained a concern. Leaders were able to describe some improvements made, including refurbishing an ensuite bathroom to ensure it is accessible, but advised overall accessibility is still inadequate and under review. Largescale estate work was planned to modernise the unit, but this could only occur if national funding was made available.

The entrance to the labour unit, including the antenatal and postnatal wards, was monitored by CCTV in real time in the hospital control room. Staff used a swipe card to enter the unit.

Both the labour ward and triage were clearly signposted. The handover room provided fixed computer screens which displayed patient information to aid with flow and safety.

Maternity equipment had improved since the last inspection, with no ongoing issues identified. The service had completed safety testing on electrical equipment within the previous 12 months and maintained and stored oxygen cylinders securely. Staff had access to the equipment and information technology needed to conduct their work safely. There were sufficient quantities of cardiotocography (CTG) machines, central monitoring and telemetry equipment. Baby resuscitation equipment was easily accessible and available for each room. This meant the service was no longer in breach of Regulation 12 Safe (care and treatment). Nationally recognised best practice would be for each room to have a resuscitaire in the room, however some of the labour rooms were not big enough, therefore the resuscitaires were kept close by.

We observed the service had not maintained some labour ward beds within the required time. All other areas recorded good compliance.

We found multiple out of date consumables within three different areas. We brought this to the attention of leaders within one area. However, when we checked the next day there was still out of date consumables within the area. This is a beach of Regulation 12 (safe care and treatment).

Staff on the labour ward, had not stored COSHH (Care of Substances Hazardous to Health) safely. We escalated this and leaders resolved this at the time with learning implemented. We found incorrectly stored COSHH materials in the antenatal/postnatal ward.

All areas visited were bright and spacious, with items stored tidily and appropriately. The wards were clean, organised and free from clutter. Staff ensured all store rooms were locked. This resolved Regulation 12 (safe care and treatment) breach.

Throughout most areas, resuscitation trolleys were accessible, tamper evident, clean and regularly checked. The emergency grab bag within the antenatal clinic area was maintained to the same standard. We found gaps in labour ward resuscitation checks and daily oxygen and suction checks.

The service had completed all fire risk assessments and identified no significant fire risks. Staff had noted a small number of minor environmental risks and logged them with the estates team, who were actively progressing remedial actions.

We observed some doors wedged open, a recurring theme across several risk assessments, which created avoidable fire safety risks and was not in line with the trust’s fire safety procedures.

Staff had access to clear, visual fire action flowcharts outlining the steps to take and individual responsibilities when the fire alarm sounded. An emergency evacuation plan was available in all clinical areas, supporting staff to respond promptly and safely in the event of an emergency.

Fire safety awareness training compliance met the trust target of 90%.

These improvements meant the service was no longer in breach of Regulation 17 (good governance).

The maternity theatre environment had improved since the last inspection. A full refurbishment programme had taken place.

The most recent healthcare ventilation annual inspection, completed in March 2026, confirmed maternity theatre ventilation system met HTM 03 01 (2021) minimum standards, with acceptable airflow performance and the theatre and air handling unit was in a good condition. The inspection had identified 3 urgent issues with actions in place to resolve these. These improvements meant the service was no longer in breach of Regulation 15 (premises and equipment) and regulation 12 (safe care and treatment) in relation to the theatre environment.

The most recent healthcare ventilation annual inspection, completed in March 2026, confirmed the labour ward ventilation system did not meet HTM 03 01 (2021) minimum standards. Multiple supply and extract air change rates were low. Some extract air changes had no flow at all. Differential pressures did not allow air flow from clean to less clean areas. This meant the service was in breach of Regulation 15 (premises and equipment) in relation to the labour ward.

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. However, staff worked together well to provide safe care that met women’s individual needs.

Safe and effective staffing processes were consistently in place across the service, with reliable oversight to ensure safe staffing levels. Handovers included discussion of staffing and patients level of support needed across the unit.

Matrons held responsibility for safe staffing, and daily cross-site safe staffing huddles reviewed clinical and midwifery staffing. Leaders used the OPEL scoring system and an accompanying escalation policy to support decision making. Leaders reviewed rotas proactively, particularly before weekends, and aligned staffing decisions with OPEL scoring to ensure risks were identified and managed.

Display boards identified which staff were on duty.

There were sufficient midwifery staff in post to meet demand, and sickness levels had improved since the last inspection.

Senior leaders used bank and agency staff to support safe staffing. Fill rates across wards were in the low to mid 80%.

The service maintained a consistent cohort of agency midwives, trained them in ward-level systems, and block-booked them in advance to support continuity, reduce variation, and enable safer workforce planning.

Women told us there were enough staff available to meet their individual needs.

Leaders used Birth Rate Plus methodology to calculate the birth to midwife ratio. Birth Rate Plus had identified a gap between the funded establishment and the staffing required for safe service delivery. The Trust Board had approved a three year plan to increase midwifery staffing in line with these recommendations.

The service planned to increase workforce headroom to 24% for all clinical staff within the current year, with particular attention to improving patient flow and maximising the delivery of frontline clinical care.

However, the service remained non-compliant with Safety Action 4 of the Saving Babies’ Lives Care Bundle, as it will take time to implement the full workforce uplift and the service has not yet fully met the required standard for demonstrating an effective midwifery workforce plan.

Since the last assessment, medical staffing levels had improved, with establishments nearly full and reduced reliance on locums.

Consultant medical staffing was stable, with minimal vacancy, minimal turnover, and significantly improved sickness absence, which was at a minimal level.

The service operated a consultant model with eight resident consultants providing on site cover and eight non resident consultants providing on call cover from home.

Resident doctor staffing was stable overall. Sickness and vacancy rates varied by tier, but were balanced operationally, and no temporary bank staff were used. A trust wide resident doctor workforce review was completed in March 2026 however no additional posts had been allocated to maternity.

The General Medical Council National Trainee survey (GMC NTS) results for the service maternity and gynaecology trainees 2025 reported a deterioration in 12 out of 18 indicators with 6 significantly below (worse) than the national average. These were Clinical Supervision, Clinical Supervision out of hours, Adequate Experience, Adequate Experience, Study Leave and Rota Design.

Staff reported a good skill mix of medical staffing.

Administrative and clerical staffing was comparatively stable, with a vacancy rate of 7%, no recorded turnover, and sickness absence at 5%.

Maternity support worker and maternity assistant staffing showed an overall vacancy rate of 64%, turnover at 11%, and sickness absence at 12%. This meant several areas were consistently operating with significant gaps. Labour ward had 69% of its rostered hours unfilled, and the ante/postnatal ward had 37% unfilled. This meant the service was unable to maintain safe and consistent non registered staffing levels, with sustained gaps and low fill rates creating ongoing operational risk.

The service had strengthened medical staffing, reduced reliance on locums and improved midwifery staffing increased stability across clinical areas. This meant the service was no longer in breach of Regulation 18 Staffing.

Managers delivered appraisals and supported staff development. Compliance remained below the trust’s 95% target, with overall appraisal rates at 78% and medical staffing at 80%. These had improved significantly from the last inspection, when compliance was 15% for midwifery staff and 42% for midwifery care assistants. These shortfalls indicated areas for improvement and meant the service remained in breach of Regulation 18 - Staffing. This meant staff did not always have the opportunity to discuss ongoing training needs in order to develop their skills and knowledge.

The service ensured training sessions were rostered into timetables to ensure staff could attend, and staff reported good access to training.

Mandatory training compliance was achieved in core areas such as PROMPT (Practical Obstetric Multi Professional Training), infection prevention and control, safeguarding adults and safeguarding children levels 1 and 2, preventing radicalisation, and key clinical safety modules including needlestick safety, medical gas safety and sepsis awareness. Scrub competency training was 100%.

However mandatory training compliance did not meet the trust’s 90% target across several nationally and trust mandated subjects, including mental capacity act and DoLS, training on learning disability and autism, safeguarding children level 3, moving and handling, adult resuscitation, patient safety level 2 and blood safety. Therefore, the service remains in breach of Regulation 12 (Safe Care and Treatment), as staff were not consistently maintaining essential clinical competencies in line with safe practice expectations.

Community midwives accessed regular refresher sessions, so they remained confident and competent in supporting home births. This meant the service was no longer in breach of Regulation 12 (safe care and treatment) in terms of improving compliance rates for practical obstetric multi-professional training.

Midwives were responsible for providing post operative recovery care once the woman had completed immediate post anaesthetic recovery. Recovery care is a specialist role normally undertaken by trained recovery practitioners, and midwives do not have the required competencies for this function. Senior leaders informed us that, once the new post-anaesthetic care unit (PACU) opens on 1 June 2026, a PACU recovery nurse will support the service, providing immediate post-anaesthetic care until women can be safely discharged to the ward.

Clinical educators provided ongoing support and had oversight of training delivery and staff competence, offering guidance, skills development and responsive advice to ensure staff maintained safe and effective practice.

The trust had employed two retention midwives to support the career development of new midwifery staff, including overseas midwives.

Newly qualified staff spoke positively about the preceptorship programme and their supernumerary time, saying they felt well supported. Staff rotated across all areas of the service as part of this programme. They attended monthly meetings with senior midwives, which they found helpful.

Leaders ensured agency staff completed a maternity skills passport before they were able to register for shifts.

The service did not always use equipment and control measures to protect women, themselves and others from infection.

Women consistently provided positive feedback about the cleanliness of the ward and environment, describing it as clean and reassuring.

Staff displayed infection prevention control data in public areas, so that people were able to see how the service kept women, babies and visitors safe from any healthcare associated infections.

Cleaning records were up to date and showed ward areas were cleaned regularly.
There was a consistently high standard of cleanliness, with most areas achieving five star ratings.

However, we observed staff had left some cleaning records blank in the labour rooms within the labour ward. The labour ward did not retain records of previous cleaning. The trust cleaning audit for labour ward and theatres had not consistently met the 98% target, ranging between 93% and 97.5%. Therefore, the service did not demonstrate it had a robust cleaning process in place to reduce the risk of infection. This is a continued breach of Regulation 12 (Safe care and Treatment).

The maternity service recorded monthly cleanliness audits on a digital platform and reported the results to the Maternity Assurance Meeting.

Staff stored equipment off the floor and maintained sterile areas, including maternity theatres and delivery rooms, to a high standard.

Handwashing facilities and hand sanitising gel were readily available in all areas visited and clear signage promoted effective hand hygiene.

The service undertook monthly hand hygiene audits, with compliance ranging between 80% and 100%, providing variable but ongoing assurance around hand hygiene standards.

Staff adhered to infection prevention principles, including appropriate use of personal protective equipment (PPE) such as aprons and gloves. They maintained bare below the elbows, washed their hands regularly, and complied with the trust’s uniform policy.

Senior leaders met regularly with the trust’s Infection Prevention and Control (IPC) team, who attended wards and contributed to oversight and improvement. Estates, midwives and infection prevention and control staff undertook a quarterly environmental walk around of the service. However, staff told us there was no infection prevention and control meetings or IPC lead in place within the service.

Sepsis awareness training compliance met the trust target of 90%.

The service managed clinical and non-clinical waste appropriately. Staff disposed of sharps correctly in labelled sharps bins.

The service did not always make sure that medicines and treatments were safe and met women’s needs, capacities, and preferences.

Although staff had made progress in strengthening medicines processes, the audit data showed that key risks in prescribing, administering, documentation and the safe and secure handling of medicines remained.

We observed medicines, including controlled drugs, stored appropriately with restricted access; record keeping we reviewed was accurate, and a clear process was in place to report any discrepancies.

Care records showed staff consistently discussed and recorded women’s current medications, vitamins and supplements at each antenatal appointment, ensuring accurate and up to date information to support safe care.

Community staff had access to Entonox for use during home births, which they transported securely in the designated pool car. This supported safe practice and ensured women had timely access to appropriate analgesia.

We looked at the resuscitation trolleys and whilst we found gaps in daily checks, no medication or consumables were out of date. The inpatient services assurance reports confirmed the service were aware of the gaps. The assurance reports showed that staff checked the resuscitation trolley weekly 75% of the time, and the drug fridge was checked only 20% of the time in February 2026. April daily check sheet was missing. This meant we were not assured that medicines were being stored at the correct temperatures.

The service had a pharmacy technician for two hours a day, with medicines audits and support from the lead nurse for pharmacy to identify and progress improvements. Senior leaders confirmed a business case had been approved to increase the pharmacy technician support.

The service continued to identify concerns about the safe and secure handling of medicines through incident reporting, controlled drug inspections, audits, and consultation with midwives. Concerns included discharge medicines being issued without a prescription, staff not always following the correct process for giving medicines, gaps in recording of controlled drugs and sometimes not storing medications safely.

The trust pharmacy service had assessed the safe and secure handling of medicines in March 2026. The report identified 3 areas of good practice and 6 as requiring improvement.

An area of good practice was in monitoring the correct use of antibiotics. In March 2026 only one dose of antibiotics was not administered. This was investigated and a SNAaK message sent out to all staff with recommendations.

An area requiring improvement was with regard to Entonox (a gas used to support pain control in birth) prescribing. Staff had administered it to some women without a prescription.

Following the pharmacy service assessment a 12-month programme of work started to support the safe and secure handling of medication, including monthly safe and secure handling of medicines teaching sessions. All midwives had attended one session.

Reviews of medicines identified variation in prescribing accuracy. For example, the correct inpatient prescribing of enoxaparin (used to prevent blood clots) injections was 100% in March 2026. However, 40% of patients discharged from the inpatient ward and 20% for patients discharged from the labour ward had not been prescribed this medication. A review of the take home medication prescribing was underway to rectify this variation.

The service used Signal (a tool that rapidly analyses data) to spot missed doses of medication. A review of missed doses in March 2026 showed the triage unit missed administering 2% of medication, the inpatient ward missed 10%, and labour ward missed 9% of medication. Missed doses can cause serious harm to a patient, impacting a patient’s outcome, emotional wellbeing, and length of stay as well as being a financial and time burden on the trust.

Whilst there were still gaps identified in medicines optimisation, the service were aware of these, were undertaking regular audits, reporting the findings and actioning improvements. This meant the service had resolved Regulation 12 (safe care and treatment).