Scarborough Hospital

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• 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 requires improvement. At this assessment, the rating had improved to good.

Leadership, management and governance promoted an open and fair culture that supported person-centred care, learning and innovation. However, governance systems were not consistently effective in ensuring the delivery of high-quality care. In particular, treatment waiting times did not meet national standards and there were delays in responding to complaints.

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 medicine care group had a shared vision, strategy, and positive culture. This was based on transparency, equity, equality and human rights, diversity and inclusion and engagement. They understood the challenges and the needs of patients and their communities.

Each speciality within the medicine care group had developed its own clinical strategy, setting clear priorities around quality improvement, workforce optimisation, digital transformation, culture, and financial sustainability. These objectives were collaboratively agreed by clinical and operational leaders during an annual planning day, ensuring shared ownership and accountability.

A key strategic focus was a cross site workforce review aimed at optimising the existing workforce, improving service delivery, and addressing consultant and specialist staffing vacancies.

Each ward had a local improvement plan aligned to the care group’s overarching priorities, promoting consistency, shared accountability, and measurable progress.

Senior leaders, allied health professionals, and other service leads demonstrated visible commitment to a positive culture through “Back to the Floor Friday” ward walkarounds. These visits enabled leaders to gain direct insight into the day to day challenges on wards, observe care practices, and engage with staff. Leaders provided immediate support where required, addressed operational issues in real time, and reinforced a culture of openness and responsiveness.

Staff consistently described an inclusive, compassionate and learning focused culture that encouraged continuous improvement.

Senior leaders acted promptly and effectively following the concerns raised about the temporary escalation spaces. They completed comprehensive ward assessments the following day to provide assurance that patients’ privacy, dignity, and safety were maintained. As a result, one area for improvement was identified around enhancing communication between ward teams and patient flow management to strengthen coordination and ensure patient centred care.

The medicine care group was led by highly capable, compassionate, and inclusive leaders who embodied the trust’s values and inspired confidence among staff and patients. Leaders at all levels had a good understanding of their services, the complexity of patient needs and the operational challenges faced by their teams. Their leadership approach demonstrated integrity, openness, and authenticity.

Senior leaders and matrons were visible, approachable, and responsive, promoting a culture of trust and safety. Matrons had protected time each morning to complete purposeful ward walkarounds, enabling them to connect directly with staff, review patient care, and support discharge planning. Staff consistently reported that leaders listened to concerns and took prompt, effective action to address issues.

Ward managers demonstrated a strong commitment to compassionate and inclusive leadership. They promoted teamwork, accountability, and patient centred values. Each had dedicated supervisory roles either three or five days per week depending on ward size, to focus on patient care discussions and ensure that personal care, nutrition, hydration, and privacy needs were consistently met.

Staff consistently spoke positively about leaders at all levels and acknowledged that they remained supportive and visible, despite ongoing pressures related to staffing and patient flow.

The leadership culture prioritised learning, reflection, and continuous improvement. The 2024 staff survey recorded a trust score of 6.7 out of 10 for “Compassionate Leadership” evidencing a supportive and positive organisational culture. Senior leaders aimed to match the best peer result of 7.5 out of 10. Although response rates were low (23%) leaders took actions to strengthen engagement and wellbeing by revising policies to ensure staff received feedback following complaint investigations and improving disciplinary processes to ensure fairness and timeliness.

Ward managers had recently taken on expanded responsibilities relating to staffing oversight and coordination. They were rostered three to five times per month to support the “Matron of the Day” staffing line. Whilst this had temporarily increased workload and stress, staff recognised the improvement in operational oversight and patient safety.

Leadership development was a clear priority across all levels. Dedicated programmes were available within the trust for matrons, ward managers, and senior nurses, with 91 trust staff completing the ward manager development programme in April 2025 demonstrating investment in professional growth and future leadership capacity.

Staff demonstrated clear understanding of their roles, responsibilities, and reporting duties, supporting a culture of accountability and shared purpose.

The medicine care group fostered a positive and open culture where staff felt confident raising concerns and speaking up without fear.

Senior leaders demonstrated a clear commitment to listening and learning, promoting a just and learning culture.

Staff described senior leaders, matrons and ward managers as visible, approachable, and responsive and said they felt supported when raising issues or seeking advice.

Staff had access to the trust’s freedom to speak up (FTSU) guardian and fairness champions, who provided confidential support and guidance. The trust’s wellbeing lead and FTSU guardian made regular visits to wards to provide support.

The trust encouraged staff to share their views through a range of feedback channels, including the annual staff survey. The 2024 staff survey recorded a score of 6 out of 10 for “staff feeling their voice was counted” for trust staff.

Senior leaders acted on this feedback and cascaded the findings across all specialities, facilitating open discussions with staff to co-produce meaningful and achievable improvement actions. Examples of these actions included:

• Protecting staff time to complete future surveys and offering small incentives, such as coffee vouchers and chance to win prizes.
• Providing laptops to help staff with staff survey completion.
• Improving “you said we did” information following staff complaints
• Creating calm wellbeing spaces for reflection and rest.
• Hosting fortnightly informal leadership catch ups to strengthen collaboration
• Relocating therapy teams closer to wards, improving accessibility and teamwork.
• Making Greatix and compliments a standing agenda item in team meetings to celebrate positive practice.
• Increasing nominations for celebration and achievement awards.

In March 2025, the trust launched a “No Excuse for Abuse” online reporting tool, enabling anonymous reporting of incidents. This initiative reinforced a zero tolerance approach to abuse and promoted the psychological safety of all staff.

The medicine care group actively promoted equality, diversity and inclusion in its daily operations ensuring that all staff had fair opportunities to develop and progress. Policies and processes supported an inclusive, respectful, and safe working environment.

The trust had six active staff networks; Women's, Carers 4 Carers, Enable, LGBTQ+, Race equality and Veterans which provided peer support and promoted awareness of diverse needs across the workforce.

The trust was accredited as a menopause friendly employer. Staff had access to wellbeing initiatives such as “Menfulness,” an inclusive social and support community. Staff also had access to a comprehensive health and wellbeing booklet containing guidance and information about available support services.

Staff spoke positively about the workplace culture and reported no negative behaviours or discrimination, reflecting a workplace where diversity and respect were embedded in everyday practice.

The medicine care group did not have consistently effective governance to manage and deliver good quality care, treatment and support. Performance relating to treatment times was not in line with national standards and there were ongoing delays in the timeliness of complaint responses.

There was limited assurance senior leaders ensured there were sufficient numbers of allied health professional (AHP) staff.

Senior leaders did not ensure medical staff consistently received required training, with compliance remaining low and highlighting the need for targeted support and improvement; leaders had identified inaccuracies in training records, initiated a data cleanse and were developing plans to protect training time for locally employed doctors.

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.

There were ongoing delays in the timeliness of complaint responses, and a significant number of actions from previous complaints remained outstanding.

We raised concerns with senior leaders regarding the privacy and dignity of patients cared for in Temporary Escalation Spaces (TES) spaces, as some were positioned very close to other patients’ beds, compromising dignity and confidentiality.

Senior leaders continued to take action to manage patient flow despite ongoing pressures from increased admissions and delayed discharges, and the continuous flow model, including the use of TES spaces, remained under review.

During the assessment senior leaders actively responded to the concerns raised about TES positioning and the associated risks to privacy, dignity, cluttered environments and safe emergency evacuation. They completed immediate privacy and dignity reviews across all wards, introduced three daily senior management walkarounds, strengthened matron oversight and used “Back to the Floor Friday” visits to reinforce standards. They also planned to raise privacy and dignity standards at the next monthly face‑to‑face clinical meeting.

Leaders did not effectively manage high risks across the medical wards, and oversight through risk registers was inconsistent. Although the registers captured issues such as referral to treatment performance and workforce shortages across consultant, nursing and AHP roles, several risks were not updated within required timescales. Specialty leads did not consistently review or update their most significant risks, and mitigation such as RTT recovery plans and targeted recruitment had not demonstrated sufficient impact. Inconsistent attendance at governance and risk meetings further reduced assurance that risks were being monitored or acted on promptly. However, leaders reported that they had merged each speciality’s risks onto a single risk register and acknowledged that significant work was still required to ensure consistency, accuracy and relevance.

We observed a small number of unattended computers on wheels (COWs) displaying patient information on medical wards and this issue had already been identified from recent weekly and monthly audits. We raised this with senior leaders, and immediate action was taken. A communication reminder was sent to all staff to ensure computer screens were locked when unattended, and an additional reminder was scheduled for inclusion in the weekly patient safety bulletin.

The care group was overseen by a quadrumvirate leadership team comprising of a medical director, associate chief nurse, associate lead allied health professional (AHP) and associate chief operating officer. They were responsible for medical care and urgent and emergency care and across York and Scarborough hospital sites. As the team was newly established with new members it was too early to assess its full effectiveness in providing consistent oversight and assurance.

Leaders introduced monthly “excellence meetings” in June 2025 to review ward performance against the trust’s quality assurance framework. Meeting minutes demonstrated that audit findings, dashboards, improvement plans and local intelligence were reviewed in real time and collaboratively by ward managers, matrons and heads of nursing. This allowed early identification of themes, variation in practice and opportunities for targeted intervention such as staff training and focused assurance checks. There was a focus on consistency and strengthening local ownership for improvements with associated timeframes for completion.

Leaders also attended the monthly quality and performance meeting, where matrons and heads of nursing presented consolidated performance summaries across all wards. This enabled them to monitor trends, have oversight of compliance and timely commissioning of additional support where needed.

The care group had a clear process for reviewing and escalating incidents, and the Patient Safety Incident Response Framework (PSIRF) was fully embedded. Learning from deaths, incidents, and complaints informed improvement activity. However, complaint investigations were not always completed within target timescales, and actions to improve timeliness were ongoing.

The care group used technology effectively to support patient monitoring, including cardiac telemetry monitoring in the enhanced care unit (ECU). Staff spoke positively about the introduction of the new electronic record system, which improved efficiency and information sharing across teams.

Most staff demonstrated good practice in protecting patients’ confidential information. Overall compliance with information governance and data security training was high, although compliance among medical staff was lower than other staff groups.

The medicine care group showed a strong commitment to working collaboratively across the local health and care system. Senior leaders and staff demonstrated a clear understanding of local system challenges and worked closely with community stakeholders and commissioners to review and improve patient pathways. They shared information, learning and best practice with partners to support continuity of patient care.

Partnership working was strengthened through data sharing agreements and a multi-agency neighbourhood model which promoted coordinated care and effective communication between primary care, local authorities, social services, integrated neighbourhood teams and ambulance services.

There were several examples of effective integrated care initiatives, including:

• Discharge to Assess (D2A): enabling patients to leave hospital promptly with ongoing assessment and support provided in the community.
• Home First approach: supporting patients to return to their own homes whenever possible rather than residential or institutional care.
• Community based frailty specialist service: enabling patients with complex needs to be managed safely at home, reducing avoidable admissions and supporting independence.

The care group medical consultant lead attended a fortnightly cross site MDT executive led meeting to discuss how to improve patient flow and discharges. The discharge hub worked effectively with social care partners to coordinate safe and timely discharges and ensure up to 48 hours of post discharge support and rehabilitation.

The care group also worked collaboratively with community partners to develop four palliative care beds at Bridlington Hospital, allowing patients to receive care closer to home and reducing unnecessary hospital admissions.

The care group described how partnerships with Whitby Hospital had significantly improved in supporting discharges following the introduction of weekly multidisciplinary meetings. These meetings strengthened communication and ensured that patient handover information accurately reflected each patient’s condition prior to transfer. This led to a reduction in complaints and demonstrated sustained improvement in joint working.

The care group actively participated in the Rapid Process Improvement Workshop (RPIW) in June 2025, working alongside Healthwatch, Health Innovation North Yorkshire and Humber, and other partners to strengthen processes for managing concerns and complaints.

The trust worked with wider community partners including Age UK, Carers Support Services, Dementia Forward and local voluntary organisations to ensure that learning from incidents was supported beyond the hospital setting.

In addition, the care group collaborated with neighbouring NHS trusts, including Hull University Teaching Hospitals (HuTH) to share learning and drive continuous improvement across the region.

The medicine care group demonstrated a strong focus on continuous learning, innovation, and improvement. Staff and leaders were committed to developing new and creative ways to improve patient experience, outcomes, and quality of life.

Senior leaders promoted a culture of learning through weekly “Back to the Floor Friday” ward walkarounds, focusing on themed areas of care as part of the trust’s Year of Quality for example, infection prevention and control, and sustainability.

The continuous flow model, though still developing, created opportunities for innovation and shared learning across the organisation.

Staff were encouraged to contribute ideas through upcoming Quality Improvement (QI) drop in sessions and a one day introduction to QI programme.

Lilac Ward had introduced improvement champions to support local initiatives, while Cherry Ward achieved positive outcomes from QI work focused on preventing deconditioning and reducing falls.

The Enhanced Care Unit (ECU), one of the first of its kind in England, provided a rapid escalation pathway for patients requiring higher levels of support, ensuring timely intervention and reducing unnecessary transfers.

On Ash Ward, staff had developed a new nutrition and hydration monitoring station and piloted a RAG rated nutritional pathway, which was due to be rolled out across other wards following positive results.

On Waters ward, staff implemented “rise and shine by 9am” to enable 3 hours of daily rehabilitation time.