Scarborough 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 requires improvement. At this assessment, the rating had improved to good. This meant people were safe and protected from avoidable harm.

We found an inclusive and positive culture of continuous learning and improvement, supported by effective systems and collaboration to ensure safe continuity of patient care. Staff delivered high quality care that met patients’ needs. There have been improvements in multiple key areas. For example, we found improvements in the completion of risk assessments, as well as in the management and oversight of nursing and medical staffing. Staff also received up to date appraisal of their work alongside support, supervision, and opportunities for professional development.

However, we found continued breaches of the regulations relating to staffing. Training compliance among medical staff remained below target; this was expected to improve following the recent recruitment of additional medical staff. There was also a shortage of allied health professional (AHP) staff; senior leaders were taking action to address this through targeted workforce planning and recruitment initiatives. Following our assessment, we issued the medicine care group with action plans.

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 medicine care group had a proactive and positive culture of safety, based on openness and honesty. Staff were encouraged to raise concerns, and safety events were investigated and reported appropriately. Lessons were learned to continually identify and embed good practice.

The most common themes of incidents were falls, pressure ulcer damage, medication, and discharge. Incidents were reviewed through established governance processes, including daily huddles, care group oversight meetings, and ward level action planning. Managers ensured that investigations were completed appropriately, with patient involvement where relevant.

There was a strong culture of learning and high level of support provided to staff. Staff knew what incidents to report and were confident in reporting them. They demonstrated understanding and compliance with the duty of candour, ensuring openness and honesty when incidents occurred.

Managers shared learning from incidents effectively. Daily safety briefings included learning from recent incidents within the care group, as well as shared learning across sites and the wider trust. Governance insight newsletters also highlighted key learning, updates such as Martha’s Rule, ongoing improvement priorities, and examples of good practice.

Staff handovers included information about incidents from the previous shift. A resident doctor had introduced a new learning approach using a ‘postcard snapshot’ format, which was extremely well received by staff and encouraged engagement in shared learning.

Staff used incident learning during reflective practice and supervision sessions to support service improvements.

The care group also promoted cross site learning through joint governance meetings, shared newsletters, and improvement training.

However, feedback to staff regarding staffing related incidents had not improved.

The medicine care group had effective systems to ensure safe and coordinated care. Staff worked collaboratively with patients, relatives, and healthcare partners to maintain safety during admissions, transfers, and discharges between wards and hospital sites.

We observed staff following clear protocols to manage transfers and discharges, including patients who were stepping down from the intensive care unit (ICU) to the Enhanced Care Unit (ECU) and from ECU to Beech Ward. Most staff reported that admission and transfer processes worked well and shared examples of good practice.

Daily safety briefings and board rounds were well structured, ensuring oversight of admissions, transfers, and discharges to support continuity of care and patient flow. We observed effective and comprehensive handovers which covered all aspects of patients’ needs.

The care group had implemented a continuous flow model at times of high operational pressureto maintain patient safety and flow. Between one and four temporary escalation spaces (TES) were available on wards to manage patient flow and reduce emergency department pressures. Staff provided examples of how the model had improved communication and teamwork. They were supported by appropriate policies and quality impact assessments were in place to mitigate risks.

During our assessment, the number of patients waiting in the emergency department reduced from 18 to 13 within a short period, demonstrating effective coordination of transfer to medical wards. However, on some occasions, transferred patients had to wait for their allocated beds to be cleaned before they could settle safely and comfortably.

Staff managed an effective discharge process using standardised checklists to ensure safe transfers. Resident doctors liaised with community professionals, including GPs, district nurses, and community pharmacies to facilitate safe discharge.

Ward based discharge liaison officers worked closely with therapy teams, patient flow teams and the trust’s discharge command centre, which operated 7 days a week. They collaborated with social services and community partners to support timely discharge, rehabilitation, and continuity of care, helping to prevent readmissions.

However, onward care packages and limited therapy availability continued to cause discharge delays, particularly for patients with complex needs. The challenges included restricted access to rehabilitation service and limited virtual ward capacity and obtaining discharge medications. In addition, some care home had cut off times for admissions.

The trust’s discharge command centre supported flow by advising on alternative pathways, such as discharging patients for outpatient follow up when appropriate.

The medicine care group had safeguarding processes in place and staff were mostly trained in safeguarding children and adults

The care group provided safeguarding training specific for staff roles on how to recognise and report abuse. The training content included recent themes and trends and also professional curiosity discussions. While safeguarding training compliance was high for most staff, medical staff remained below target, with a completion rate of 68% for adult training (consultants 89%) and children training 64% (consultants 83%).

Staff demonstrated a good understanding of safeguarding procedures and were confident in making alerts and care records showed appropriate documentation. Between August and October 2025, the care group raised 30 safeguarding concerns with the local authority. In most cases, safeguarding referrals had already been completed for patients during their care in the emergency department.

Staff worked closely with the safeguarding team, who provided responsive advice and support.

All related policies were clear and comprehensive.

The medicine care group worked effectively with patients to understand and manage risks. Staff provided care that was safe, supportive, and person-centred.

We observed regular effective handover meetings, safety huddles, ward and board rounds. These were attended by all relevant staff who were able to share information and escalate concerns. We observed excellent examples of staff sharing key information to maintain patient safety such as falls risk, mobility, care plans, suitability for step-down or discharge, dietary needs, and infection status. These meetings evidenced collaborative decision making and ensured consistent oversight.

Managers coordinated all meetings around consultant ward rounds to ensure patients with the highest needs were prioritised, supporting timely decisions and safe, effective care.

The care group placed strong emphasis on staff competency and patient safety, particularly in reducing falls. Patients identified as being at risk of falls wore yellow wristbands, allowing staff to easily recognise them and provide appropriate support. There was high compliance with falls prevention training.

There had been sustained improvements in the completion and consistency of risk assessments, which staff reported were now well embedded in daily practice. Staff escalated risks appropriately and discussed these with patients to support shared decision making. Consultants reviewed patients across different specialty wards to monitor progress and ensure a coordinated approach to care and treatment.

Managers demonstrated a good understanding of the risks on their wards. However, their top risks did not always align with the care group’s risk register.

We reviewed the risk register and each specialty had its own set of risks, with mitigation actions, which were discussed at monthly meetings. However, not all risks were updated in a timely manner, and some had not been reviewed within the required timeframes set out in the risk guidance. There were also instances where staff absence from meetings limited opportunities to provide necessary updates.

Medical staff had improved the compliance for sepsis awareness training to 88% and audit data showed high compliance for sepsis screening, fluid management, and taking blood cultures before administering antibiotics.

The medicine care group did not always detect and control environmental risks to maintain a consistently safe setting.

We observed patients being cared for in temporary escalation spaces (TES) located in unsuitable areas. This included spaces obstructing internal fire doors and evacuation routes which meant these patients did not have access to call bells. These concerns were immediately escalated to senior leaders, who acknowledged the issues and confirmed that staff had not consistently followed policy. In response, they took prompt action by introducing three daily senior management walkarounds to monitor compliance and updated the standard operating procedures to strengthen matron oversight.

The care group were revising the continuous flow model and use of escalation spaces as part of its winter planning. These measures provided assurance the issues had been recognised and that current oversight and safety monitoring had been strengthened.

On most wards, we observed equipment and furniture stored in corridors which created a cluttered environment which would obstruct access during emergencies. We found an unused ward, behind an evacuation route door, being used to store furniture and equipment. We observed items blocking internal fire doors and evacuation routes, posing potential risk to emergency evacuations. These issues had been identified on recent audits. Again, we escalated these concerns to senior leaders who took prompt action in ensuring corridors and doors were clear.

Following the assessment, senior leaders confirmed that staff were able to describe fire safety procedures clearly which included horizontal evacuation protocols. In addition, they provided evidence that compliance for mandatory fire safety training was 90%. We found fire extinguishers were in date and routinely tested and staff had access to fire risk assessments.

We found the storage of controlled substances hazardous to health (COSHH) had improved. However, on one elderly care ward, we found COSHH regulated substances stored unsafely because the swipe door entry to a cleaning room had been broken for six months. This issue was immediately escalated, and the door was repaired within 24 hours.

Most wards had secure entrances and exits with good visibility from nurses’ stations although the layout of some areas limited full oversight. The space around patient beds had improved along with the availability of oxygen and suction at every bedside. Patients in these beds had access to call bells.

Staff reported having access to enough equipment such as resuscitation trolleys and hoists. Equipment was easy to order and deliveries were prompt, with bariatric equipment typically arriving within two to three hours.

Resuscitation trolleys were tamper evident, clean, and subject to daily and weekly checks, with records confirming compliance.

The medicine care group could not always ensure there were enough qualified, skilled and experienced staff. They did not consistently make sure medical staff received training. However, staff received effective support, supervision, and development opportunities and worked well together to provide safe care that met patient’s individual needs.

Senior leaders held twice daily nurse safer staffing meetings and used the SafeCare system to monitor and respond to real time nurse staffing risks.

Ward managers could escalate concerns to the “Matron of the Day” and provided examples of how staffing pressures were managed, such as reallocating bay responsibilities to maintain safe cover. Despite these measures, some staff told us that increasing patient dependency had affected workload and did not always have full break times.

Monthly safer staffing reports were submitted to the trust’s resource committee, providing oversight and assurance on safe nurse staffing and sustainable workforce deployment.

Nursing staff

Nurse staffing had improved. Within the medical and urgent and emergency care group, however vacancies were 11% which were worse than the trust average of 6%. Sickness and turnover rates were both 4%, indicating workforce stability.

The majority of rota gaps (78%) were filled through bank and agency staff, representing an improvement and just below the 80% national target. Ward managers told us that healthcare support worker vacancies remained high, with one ward reporting eight vacant posts, placing additional pressure on existing staff.

Senior leaders had undertaken a full nursing establishment review, identifying the need for an uplift of 42.68 whole time equivalent (WTE) to maintain safe staffing levels. A targeted recruitment programme was underway, including the onboarding of over 120 newly qualified nurses from universities and registered nursing apprenticeship programmes.

Medical staffing

Medical staffing had also improved. Vacancies across the care group were 4%, including 11 consultant vacancies and active recruitment was in progress. Some specialties were supported by cross site cover from York Hospital, maintaining safe staffing and continuity of care.

The sickness rate was 4%, and below the national average of 5%. The majority of rota gaps (90%) were filled using locally employed and temporary doctors. The overall turnover rate was 23%, excluding rotational resident doctors. For Consultants and Associate Specialist (SAS) doctors turnover was 13%, consistent with the trust average, while locally employed doctors had a higher turnover of 33%, reflecting the fixed term nature of their roles.

Senior leaders had undertaken a resident doctor establishment review, identifying the need for an increase of 7.35 WTE, bringing the total to 55.35 WTE to ensure safe and consistent medical cover. Staff on the Enhanced Care Unit (ECU) confirmed there was always one resident doctor per acute, cardiology, and respiratory specialty, with adequate 24 hour medical cover.

An acute medical on call rota was in place, with consultant cover during evenings and weekends and non resident cover overnight. There was no out of hours rota for elderly medicine; however, the acute and general internal medicine consultant provided cover out of hours.

Allied Health Professionals (AHPs)

Improvements had not yet been made to ensure sufficient numbers of AHP staff, resulting in a continued breach of regulation. Workforce pressures remained significant, with vacancy rates of 11%. A recent workforce review identified a shortfall of 47.4 WTE posts, representing a substantial staffing gap. Senior leaders were working with HR and recruitment teams to address these shortages through targeted workforce planning and recruitment initiatives.

Training and competency

The care group provided mandatory core and required learning to ensure staff had the skills to deliver safe and effective care. Compliance had improved, with 85% completion for core training and 83% for required learning, both slightly below the trust target of 90%.

Compliance had improved for Oliver McGowan (Learning Disability and Autism) and Sepsis training. Annual and four yearly Adult Life Support training remained good for nursing and non-clinical staff.

For overall medical staff, compliance remained low at 65%. Consultants demonstrated higher levels of compliance, with rates ranging between 83% and 100%. The modules with the lowest completion rates were practical aseptic non-touch technique (38%), patient safety (43%), meeting nutritional and hydration needs (52%) and blood safety (54%). In addition, compliance remained below target for Mental Capacity Act & Deprivation of Liberty Safeguards (43%) and PREVENT Awareness (69%), Safeguarding Adults (68%), Safeguarding Children (64%) and Annual Adult Resuscitation (65%). As a result, the care group remained in breach of this regulation.

Senior leaders explained that 44 new medical staff (representing 31% of the medical workforce) had recently joined the service and were still within their 12-week grace period, contributing to the overall lower compliance figures.

Senior leaders monitored compliance closely, and staff overdue on training received automated reminders.

Specialist and Induction Training

We heard positive examples of bespoke respiratory and cardiology training delivered to staff on the Enhanced Care Unit (ECU). Specific training was delivered to staff on certain wards; however, low numbers of staff had completed specialist modules such as pressure ulcer prevention, enteral feeding, and the management of feeding devices.

A cohort of 22 newly registered Band 5 nurses had successfully completed the trust’s competency framework, supporting a consistent approach to safe and effective clinical practice.

Ward managers provided all new staff with an appropriate local ward induction, including agency and locum staff which was an improvement. Staff described inductions as comprehensive and supportive, helping them settle into their roles. Newly qualified nurses received a minimum two week supernumerary period, which could be extended based on individual needs to ensure they were confident and competent before taking on full responsibilities.

The medicine care group effectively assessed, managed, and controlled infection risks, promptly escalating concerns to the trust’s Infection Prevention and Control (IPC) team. IPC practices were well led, embedded across wards demonstrating continuous improvement and responsive action when issues were identified.

There was a consistently high standard of cleanliness, with most wards achieving four or five star ratings. Handwashing facilities and hand sanitising gel were readily available in all areas visited. However, no posters were displayed on wards to instruct staff or visitors on effective handwashing techniques.

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

The IPC team provided ongoing support and carried out regular audits of environmental cleanliness. Compliance remained high for hand hygiene, and for commode and bedpan cleanliness, with several wards achieving sustained excellent performance. Low scores were linked to isolated issues, including removal of wipes and gels from patient rooms and the presence of soiled commodes.

A targeted IPC improvement programme, including regular audits and focused interventions, resulted in sustained reductions in Clostridioides difficile (CDI) infection rates on two wards.

All patients were screened for infectious diseases on admission or if symptomatic, with results promptly shared with staff. The IPC team ensured appropriate management and isolation, effectively using single rooms to maintain safety while supporting patient flow.

The care group monitored performance against mandatory Healthcare Associated Infection (HCAI) surveillance indicators. Overall performance had improved, although rates of Klebsiella and Pseudomonas bacteraemia had slightly worsened compared with the previous year.

Senior leaders met with multidisciplinary clinical teams following any reported cases to complete post infection reviews, identify actions and share lessons learned. The IPC team also delivered focussed education sessions and study days, and staff were compliant with mandatory IPC training.

“Back to the Floor Friday” ward walk recommendations included introducing standardised signage at soap dispensers to remind staff to wet their hands before applying soap, supporting consistency in hand hygiene practice.

All clinical and non clinical waste was managed appropriately.

The medicine care group made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Staff involved patients in planning and discussing their medicines, including when changes occurred.

Medicines were stored securely on all wards visited. Drug trolleys were tethered to anchor points, and designated nurses held the keys. Clinical areas used for medicine storage were locked and accessible only via swipe card. Resuscitation trolleys were checked daily and weekly to ensure emergency medicines were available, and oxygen was stored appropriately in designated areas.

We found expired fluids stored in one of the ward’s clinical rooms. We escalated this to the ward manager who said that it was the responsibility of the ward staff and the pharmacy teams to regularly check expiry dates and rotate stock. However, the policy stated this was the responsibility of the ward manger.

Patients’ own drugs (PODs) were encouraged for use during admission to minimise waste and ensure timely availability. These were stored securely in bedside lockers, and no medicines were found unattended.

Due to operational pressures, medically fit patients awaiting discharge paperwork were transferred to the discharge lounge.

Supplementary paper prescription charts were sometimes used alongside the electronic prescribing and medicines administration (ePMA) system. However, these were not always mirrored on ePMA, creating a risk that staff may be unaware of medicines recorded only on paper charts. This practice increased the risk of missed doses and compromised continuity of care.

An emergency medicines cupboard was available for wards to access urgent stock without contacting pharmacy.

Medicines reconciliations (a list of medicines a patient was taking prior to admission, compared to what is currently prescribed), was done manually by staff each morning using an electronic filtering system. This could lead to high-risk patients being missed off this list, as it is not yet automated.

However, medicines reconciliations seen used numerous sources to ensure the information was correct and up-to-date. Discrepancies were clearly recorded and visible in the electronic prescribing system, allowing staff to track any changes made during admission.

Improvements have been made to achieve the local target of getting 50% of medicines reconciliations completed within 24 hours of admission.

Performance against the medicines reconciliation target showed steady improvement from 46% in March to 51% in August 2025 and for critical patients 73% to 83%.

The trust’s target for discharges completed within two hours was consistently achieved, averaging 97% between March and August 2025. Critical medicine dispensing times had also shown consistent improvement during the past six months.

The pharmacy team produced regular medication safety bulletins for care groups, highlighting incidents, lessons learned, and actions taken to reduce future risks.

Improvements were seen with ensuring time critical medicines were given when prescribed, and the completion of the patient’s own medicines book on admission and discharge.