The York Hospital

On this page

• 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

At our last inspection we rated this key question as inadequate. At this assessment we rated this key question as good. 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.

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of women who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

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.

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.

The Service had a clear vision, strategy and improvement plan aligned to the NHS 3-year delivery plan for maternity and neonatal services. Staff from all parts of the service had input into this.

Staff told there was a positive culture and a good working relationship between midwives and medical staff.

Staff described a significantly improved culture overall, although leaders recognised there was still small pockets of the workforce who did not feel fully engaged. The organisation had experienced leadership instability, with a fifth Director of Midwifery appointed in four years, and leaders were aware this had contributed to uncertainty for some teams.

Staff who were new to the service told us staff were friendly, approachable, and worked well together.

Staff had been involved in producing a new estate plan and they were positive about it.

Staff had been involved in discussions and decisions about the revised staff allocation for the service following the Birthrate Plus review and approval by the Board for the funds. Staff had worked together to assess needs, discuss options and develop their own solution.

Leaders told us they saw a continued focus on visibility, communication, and supportive leadership as essential to sustaining progress and strengthening trust across teams.

Staff told us face to face meetings were not routinely in place, and that it had been difficult to embed this process. They described challenges with effective communication sharing, which affected consistent leadership communication across teams.

Leaders told us attendance at departmental meetings faced challenges owing to shift work, staff shortages and issues such as cost of parking. Different options had been trialled, but none had been effective. Leaders used more informal settings, such as daily huddles, staff welcome and governance boards, SNAaK bites, newsletters and ad hoc debriefs, to ensure messages and updates were provided using 5 times in 5 different ways to communicate messages.

Leaders told us they planned to refresh ward meetings once core staff had settled into their designated areas, to strengthen communication and improve consistency.

Leaders had held quarterly off-site staff engagement days over the past two years. Subjects discussed include priorities, risks, and aspirations for the service.

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 reported feeling well supported by managers and senior leaders, who were visible, accessible, and responsive to day‑to‑day concerns. When needed leaders assisted with clinical work.

Staff consistently praised the Director of Midwifery for her visible presence and approachable leadership style. A new Deputy Director of Midwifery was due to start, and the service had an active recruitment process underway for the Head of Midwifery post.

The service had appointed a Transformation Lead Midwife to support improvement work.

The clinical director role worked across both York and Scarborough maternity hospitals. She was approachable, open and honest, and shared a clear vision for the service.

There was evidence of leadership support for workforce development, including succession planning and training opportunities, such as coaching programmes and complaints management courses.

The service demonstrated evidence of succession planning and provided staff with opportunities to develop their skills and progress into more senior roles.

Staff had a clear understanding of their roles, responsibilities, and reporting arrangements. Staff told us this was beginning to bring greater stability to the senior leadership team.

The service did not always foster a positive culture where people felt they could speak up and their voice would be heard.

The trust had presented the most recent Trust Freedom to Speak Up Annual Report to the Board in 2025. The report acknowledged the number of staff from midwifery reporting through the trust Freedom to Speak Up process had significantly dropped. The report acknowledged this could suggest reduced engagement, resolution of prior concerns, or barriers to speaking up. Alternatively, the report advised it could reflect growing confidence in escalation of concerns via line managers.

Most staff we spoke with were not aware of the trust’s freedom to speak up service, and some did not know who the guardians were or how to contact them. This indicated gaps in the visibility and communication of the freedom to speak up offer, despite systems being in place to support speaking up.

In March 2026, the Freedom to Speak Up Guardian and the trust staff Health Being Lead undertook a session for maternity staff to raise awareness of the support available.

Staff told us their managers were approachable and helpful with any concerns they wished to raise. Staff told us the Professional Midwifery Advocate midwives were supportive with any issues which required resolving.

Staff had participated in a recent cultural survey and attended four away days where they shared their opinions.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff were able to access flexible working arrangements, including flexible hours and job‑sharing, to support personal circumstances such as caring responsibilities and health needs. The service leaders had met every two weeks to review all flexible working requests to ensure fair and holistic decisions.

The service told us the trust had introduced health passports, and managers consistently implemented reasonable adjustments, including modified shift patterns and occupational health support.

The trust Peoples Strategy identified equality, diversity and inclusive practices as an important part of their ambitions. The trust had shared equality objectives with staff. The trust reported performance against the NHS Equality Delivery System (EDS) 2022, the NHS Workforce Race Equality Standard (WRES) and NHS Workforce Disability Standard (WDES), with action plans in place to reduce the gaps to meet the standards.

An anti-racism steering group was in place committed to creating workplaces and services where everyone feels safe, valued and supported, regardless of their background, faith identity. Objective had been identified and clear metrics set aligned to WRES standards. Staff had been offered anti-racism training.

The trust had active staff networks, including, Carers Network, Race Equality Network (REN), Disability (Enable) Network, Women’s Network and LGBTQ+ Staff Network and Veterans Network. These networks provided peer support and raised awareness of diverse needs.

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 and leaders provided consistent positive feedback about the effectiveness of the service’s governance systems and processes. They highlighted regular multidisciplinary assurance meetings which supported oversight, shared learning and accountability.

A formal governance structure and clearly defined operational structure was in place from ward/department to the Family Health Care Group Board. We reviewed minutes from a cross section of meetings. Patient stories were one of the agenda items discussed at the Maternity Directorate meetings. Leaders held regular meetings to review guidelines and audits, safety events, screening and the services improvement plan.

The service held a Maternity Assurance Group Meeting to review key areas including the improvement plan, incentive scheme, quality and safety metrics, complaints, safety events staff engagement, training compliance, staffing levels, and service diversions.

A maternity dashboard was in place which provided a summary of maternity performance across key metrics. Leaders reported the dashboard through the Maternity Assurance Group and into the maternity quality a safety report which is presented to the trust board.

Leaders held annual planning days which covered: where we are now, priorities for the next year, risks and support needed and looking ahead.

The Maternity Directorate Meeting and Maternity Assurance Group oversaw governance of the Maternal Care Bundle, Saving Babies Lives Care Bundle v3.2 and Maternity Incentive Scheme (MIS) Year 7, with named leads and key holders identified. The service submitted a formal report to the trust board.

The Maternity and Neonatal Safety Champions submitted an annual report to the Board. They had issued 8 safety concerns in the last 9 months of 2025 with the top three concerns relating to reduction in workforce, women not receiving pain relief when requested and delays in receiving essential equipment. The champions undertook monthly safety walkabouts. Top three themes reported as part of these walkabouts were workforce, environment, and lack of space for community clinics in GP surgeries.

All matrons presented a monthly summary report to the maternity directorate meeting, detailing activity, assurance, quality and safety and quality improvement for their areas.

Wards and units displayed standardised governance boards with clear sections such as service improvements, patient‑experience feedback, achievements for the month and a ‘shining star’ recognition area. These provided staff and women with a consistent overview of current priorities and areas requiring action.

The service managed risks in line with the trust risk management strategy. Staff told us how they would escalate risks to their line manager who would discuss these with their matron. The department governance team would add the risk to the risk register. The service discussed all risks at the quarterly maternity directorate meeting, and all risks rated 12 and above taken to the monthly Care Group Board. The service presented a risk report to the trust risk committee every two months for discussion and assurance.

We reviewed papers which identified service risks were discussed at directorate and care group level. The electronic reporting system used for managing risks identified the trend and movement with the risk. Some dates for risk review had not been updated within the electronic reporting system.

Multiple digital systems were in use. Staff used these effectively to book scan appointments, share information and support smooth coordination across sites. Staff described the systems as workable and explained they could navigate between platforms to book women appropriately and share information with relevant teams.

The service had secured funding for a data midwife to ensure staff could complete audits and report findings from the bespoke maternity electronic patient record system. The service had a business continuity plan in place to support the service if the electronic patient record system failed. Staff locked computers when they were not in use.

Staff and leaders provided consistent positive feedback about the effectiveness of the service’s governance systems and processes, highlighting regular multidisciplinary assurance meetings which supported oversight, shared learning and accountability.

This meant the service was now not in breach of Regulation 17 (good governance) as there is evidence of a robust governance and risk management process in place with an effective system to assess, monitor and drive improvement.

The service clearly understood and performed their duty to collaborate and work in partnership, and services worked seamlessly for people. They always share information and learning with partners and collaborate for improvement.

The service had excellent collaborative working with their local MNVP service. The antenatal clinical area displayed posters showing women how to contact the local Maternity and Neonatal Voices Partnership teams.

The service held quarterly meetings with council partners, Healthwatch, and volunteer groups, which service users attended. At the meeting, MNVP shared examples of positive and negative findings from visits to the maternity service and women who had used the service raised issues. The service provided updates on staffing, estates, and quality improvements.

The service has incorporated Whose Shoes? a new way of engaging with women about maternity services into their Maternity & Neonatal Single Improvement Plan.

The service held monthly MDT meetings with Leeds Maternity service to discuss patients identified as requiring more complex care.

The digital system enabled effective sharing of information with GPs and health visitors, supporting continuity of care and timely communication across agencies. Maternity, neonatal and GP teams worked together to share data through the Yorkshire and Humber Care Record, strengthening integrated working and ensuring key information was accessible to all relevant professionals.

Midwives from all services collaborated effectively with local authority safeguarding teams, social services and health visitors, enabling them to access local knowledge and support when needed.

The amethyst midwife team worked across mental health and community services, and with the children’s ward to support families, to connect care, and support women with additional needs before birth, and after birth. They also worked with another trust to support development of a transgender policy.

Safeguarding midwives worked in partnership with the City of York’s Early Help Team, delivering masterclasses to strengthen staff understanding of multi‑agency pathways and ensure joined‑up support for families, supporting a more aligned and cohesive safeguarding response across all areas served by the maternity service.

Safeguarding midwives supported community midwives and attended all strategy meetings across the three local authorities. They were actively involved in multi‑agency approaches to pre‑birth planning, child protection processes and discharge planning, ensuring consistent, coordinated safeguarding practice across the system.

Digital midwives worked in partnership with GPs to ensure the correct electronic forms were available for community midwives to upload to shared digital systems. This included key documents such as the transfer of care and booking care forms.

The service shared discharge letters electronically with GPs, and women’s care records were accessible for review across all local hospitals (apart from Leeds where there is a robust work around).

This supported timely information‑sharing, continuity of care and consistent clinical decision making across organisational boundaries.

The service had co-produced Personalised Maternity Care Plans with MNVP, representing a clear improvement in experience and engagement. They had collaborated with MNVP around the “birth reflections” offer which meant women could self‑refer into the service and receive one‑to‑one support from midwives, with MNVP representatives involved. This provided an accessible, supportive space for women to discuss their experiences.

Leaders encouraged independent midwives to attend the maternity unit, meet the staff and view the labour to ensure continuity of care for women.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice.

The service, with women’s input, had developed a ‘Strategic Approach to Improvement’ plan, comprising four clearly defined workstreams, each led by different leaders, with input from staff at all levels, using a recognised quality improvement programme.

Leaders reported the improvement plan via a live dashboard, identifying at which phase the improvements were. There was a robust governance process to provide assurance both at service level and board level.

Staff at all levels told us there had been opportunities to be part of quality improvement projects. Whilst the time to undertake these quality improvements had been difficult, most staff had embraced the opportunity and could see the real benefits it was bringing to the safety for women and babies.

CQC reviewed 3 quality improvement projects, induction of labour, acute scanning and planned caesarean birth. All had clear aims, start and end metrics, actions required with outputs and impact. The service produced guidelines, had written business cases and produced communication posters for staff and patients. Leaders used audits to monitor improvements in treatment and processes.

Senior leaders described a quality improvement project which had focused on enhancing provisions for birthing partners. The service had been identified as a national outlier in the 2025 CQC Maternity Survey, supported by themes emerging from complaints, patient feedback and the MNVP. Staff had begun to develop a clear, measurable description of improvement statement (AIMS) they intended to achieve and had established a multidisciplinary working group to co‑design solutions and drive the project forward.