Scarborough Hospital

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

At our last inspection we rated this key question as requires improvement. At this assessment, the rating has remained as requires improvement.

However, we found breaches of regulation relating to good governance and complaints. These were to delays to patient’s care and treatment as the waiting times for treatment, which did not meet national standards. There were delays with complaint responses and completion of actions relating to complaint investigation.

This meant services were not always planned or delivered in ways that met people’s needs.

Following our assessment, we issued the medicine care group with action plans.

We have not awarded this service a score for Responsive.

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

The medicine care group ensured patients were at the centre of their care and treatment decisions. Staff worked in partnership with patients, and their families, to respond to changes in individual needs and preferences.

The care group strengthened its focus on person centred care and ensuring fundamental care needs were consistently met. Robust nursing quality governance frameworks supported staff to deliver safe, consistent, and compassionate care across all wards.

Staff understood what was most important to each patient and provided care that met their physical, emotional, and social needs. Patient care records were personalised and demonstrated a holistic approach.

The trust had introduced a dedicated support team to enhance personalised care delivery, providing assistance with feeding, hydration, and offering one to one supervision.

Compliance with risk assessments linked to person centred care had significant improved, with most wards achieving rates of 90% or higher. This included improvement in compliance with the Malnutrition Universal Screening Tool (MUST) to 87% up from a previous range of 5.6% to 80%. However, the compliance against commencing Venous thromboembolism (VTE) prophylaxis within 14 hours had not improved and remained around 50%. Managers were proactive in reviewing and assuring the completion of all required risk assessments, including VTE assessments, as part of their routine audit processes.

We observed nutritional requirements clearly displayed on patient charts and bed boards, supporting staff to deliver consistent and personalised care. Patients’ dietary needs were accurately recorded and monitored through food and fluid charts, and food menus were aligned with national dietary guidance. Staff made timely referrals to dietitians and other specialist nutritional services where required.

On Ash Ward, we observed an example of outstanding practice, where a dedicated nutrition and hydration monitoring station had been introduced to strengthen oversight and promote patient wellbeing.

Performance data for patients being reviewed by a consultant within 14 hours of admission remained high and stable at 88% over the previous 12 months. This supported prompt clinical assessment and continuity of person centred care.

Staff in the discharge lounge described person centred care as integral to the discharge process. They ensured patients’ individual needs, preferences, and support arrangements were fully considered prior to discharge, promoting safe and well coordinated transitions of care.

The medicine care group demonstrated a clear understanding of the diverse health and care needs of people and their local communities. Care was coordinated, joined up, ensuring that patients experienced continuity and were supported to make informed choices about their care and treatment.

The Macmillan Recovery Package supported patients living with and beyond cancer. Cancer specialist nurses delivered personalised health and wellbeing interventions.

Endoscopy staff collaborated closely with voluntary and community sector organisations (VCSEs) to share accessible information about endoscopy procedures, helping to ensure that harder to reach patients were supported to attend appointments and receive appropriate care.

The medicine care group ensured that patients and staff had access to accurate, up to date information presented in formats tailored to individual needs

Patients could access a wide range of information leaflets and booklets on wards and via the trust’s website, supporting understanding of conditions, treatments, and self-care.

The cancer specialist nurses had developed an information leaflet for patients completing lung cancer treatment to promote ongoing self management and wellbeing.

Staff accessed up to date guidance, standard operating procedures, and over 400 procedure specific consent documents via the trust’s intranet. Additional learning resources, including speciality medicine training videos such as the “sip test”, were available on the trust’s learning hub to support staff development and clinical competence.

The digital enabling strategy outlined plans to expand digital communication tools for patients, including online therapy sessions and enhanced patient engagement platforms.

Most signposting across wards was clear and accessible; however, signage to the temporarily relocated discharge lounge required improvement due to ongoing building works.

The medicine care group had ongoing delays in the timeliness of complaint responses, and a significant number of actions from complaints remained outstanding. However, staff encouraged patients and families to share feedback, ideas, and concerns and staff involved them in their decisions about their care.

Complaints were not always investigated within target timescales. Performance data for September 2025 showed:

• 60% of concerns were closed within the 10 day working day target
• 51% of standard complaints had been closed within the 30 days working day target
• 20% of complex complaints had been closed within the 45 working day target

There were 92 complaint investigations with outstanding actions.

A total of 49 complaints had been received over the previous six months.

In addition, there were significant delays within the trust’s patient advice and liaison service (PALS) in forwarding complaints for investigation. This issue had been escalated to the trust Board for oversight and action.

To improve complaint responsiveness, ward managers were allocated additional management time to focus on patient experience and complaint handling. Senior leaders maintained strong oversight, with the most common themes relating to discharge processes, clinical treatment, and communication.

Learning from complaints was integrated into ward improvement plans, and outcomes were shared through safety briefings and governance meetings to promote learning and service improvement.

A patient experience group had been introduced with a dedicated focus on identifying patient experience theme and driving targeted improvements. Their current workstream was focused on enhancing communication between staff and patients.

Staff were reminded to use structured frameworks such as SBAR (Situation, Background, Assessment, Recommendation) during handovers and ward rounds enhance clarity and patient engagement.

Each ward displayed welcoming noticeboards near entrances for example one poster stated, “We are here to listen and help,” reinforcing a culture of openness and engagement.

Family involvement was routinely discussed during board rounds and clearly documented in patient care records ensuring relatives were informed and included in care planning.

Waiting times from referral to treatment, and arrangements to admit, treat and discharge were not consistently in line with national standards and showed limited evidence of improvement. However, patients were generally able to access services when needed and received appropriate care once admitted.

The trust remained classified as a Tier 2 organisation for elective recovery and continued to fall short of national Referral to Treatment (RTT) performance standard of 92%. The proportion of patients waiting less than 18 weeks had increased to 57% from 51%. This remained a breach of regulation as further work was required to achieve consistent, equitable, and timely access to care across all specialties.

Despite these challenges, measurable progress had been made in reducing waiting times:

• No patients were waiting over 78 weeks (previously 86).
• The number of patients waiting more than 65 weeks reduced from 949 to 47.
• Those waiting over 52 weeks decreased from 3,606 to 2,034.
• The mean waiting time for incomplete pathways improved from 21.4 to 18.5 weeks.

National benchmarking (August 2025) showed the trust ranked 118th for RTT performance, compared with 151st previously, reflecting steady improvement.

The trust did not meet the Faster Diagnostic Standard (75%) which states “patients should receive a definitive cancer diagnosis within 28 days of an urgent GP referral”. The “Cancer Waits Peer” comparison places the trust in the lowest 25% of trusts in England, as well as within the Northeast and Yorkshire region. In June 2025, the trust saw 70% of patients (2,353 in total) receiving a diagnosis within 28 days with 50% of urological and 57% of lower gastrointestinal cancer patients received a diagnosis within the required timeframe. In addition, the national cancer waiting time targets were not achieved, partly due to inter hospital transfer delays and complex internal pathways. However, the trust met the target for “patients should be treated within 62 days of a referral” for cancer.

There were ongoing delays for patients awaiting specialist treatment relating to RTT and cancer in several areas, particularly cardiology and respiratory, with prolonged waits for diagnostic tests. Transfers to tertiary centres were also delayed due to limited bed availability. This impacted on overall performance and patient flow. We raised our concerns with senior leaders who told us they were taking action to achieve consistent and timely access to care across all specialties and completed clinical prioritisation of waiting lists. In addition, they mitigated risks where possible by outsourcing to York Hospital and other external providers.

Discharge processes were effective, with 90% of medically fit patients leaving hospital within 24 hours of being declared fit. Staff followed clear admission and discharge criteria, and the discharge lounge supported safe and timely transfers, particularly for patients awaiting transport or community placements.

The trust monitored length of stay and discharge delays to identify where patients remained in hospital unnecessarily and to support timely patient flow.

Between 5 and 12 October 2025, data showed:

• 102 patients (12.6%) no longer met the criteria to reside
• 116 patients (14.4%) had been in hospital for more than 21 days “super stranded”
• 381 patients (3.7%) had been in hospital for more than seven days “stranded”

The trust ranked 32nd of 134 nationally for average bed days lost, indicating a notable improvement since 2024.

Staff and leaders actively listened to feedback and information and tailored support and treatment accordingly.

Staff promoted a culture in which patients and their relatives felt empowered to share their views and contribute to decisions about their care. Feedback was valued and used to improve patient experience and equity of access across services.

Staff in medical care demonstrated a strong commitment to equality, diversity, and inclusion, ensuring that protected characteristics were consistently recorded and used to tailor care to individual needs.

The care group had completed equality impact assessments for all relevant policies and procedures, ensuring these did not disadvantage people with protected characteristics or those in vulnerable circumstances.

Compliance with Equality, Diversity, Inclusion, and Human Rights training was high at 95%, demonstrating a strong organisational commitment to inclusive and equitable care.

Patients nearing the end of their life were supported to plan for important life changes, giving them time to make informed decisions about their care and future wishes.

Staff recognised the importance of early discussions about care preferences at the point of admission. They ensured this information was clearly recorded and shared, enabling care to be delivered in line with each patient’s individual needs and choices.

Patients receiving end of life care were cared for in the Autumn Room on Juniper Ward or in side rooms on other wards. Staff used an “autumn leaf” symbol on patient doors as a discreet reminder to provide additional support and reassurance to patients and their relatives.

The palliative care and discharge liaison teams were actively involved in personalised care planning. Staff had completed end of life care training, and new resident doctors received awareness training on the trust’s end of life processes as part of their induction.

Referrals to the palliative care team were completed appropriately. Although the team had capacity to provide only a three day service, staff described them as “brilliant” and noted their efforts to join ward rounds whenever possible. However, demand for the service had doubled over the past year, leading to longer waits, up to five days for patient reviews and two days for urgent cases.

Patients were offered spiritual, pastoral, and religious support, with access to a chapel, prayer room, and prayer trees for written messages. Staff also used comfort boxes to provide emotional and practical support to patients and relatives.

The care group showed improvement in the documentation of individualised end of life care plans, increasing to 87% from 65% in the previous year, according to the National Audit of Care at the End of Life (NACEL).

Patient records demonstrated 100% accuracy in documenting palliative and end of life care, including four hourly monitoring, timely anticipatory medication, and assessment of hydration and nutrition needs. Documentation relating to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) and Recommended Summary Plans for Emergency Care and Treatment (ReSPECT) decisions was also appropriately completed and up to date.