Scarborough Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last inspection we rated this key question as requires improvement and this improved to good at this assessment.

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that women’s care, support, and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

We have not awarded this service a score for Effective.

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

The service made sure women’s care and treatment was effective by assessing and reviewing their health, care, wellbeing, and communication needs with them.

Care records and personalised treatment plans were clearly documented following admission and kept up to date to reflect identified needs.

Women reported feeling involved in decisions about their care and delivery plans and records showed risk assessments were completed consistently.

Daily nursing handovers included discussion of risks, and onward referrals were completed where required. Midwifery support workers assessed the needs of women arriving for antenatal clinic appointments, including completing observations, urine testing, and an initial conversation to understand any concerns. This early assessment helped reduce waiting times and ensured women felt supported on arrival. Midwifery support workers were also able to discreetly escalate any concerns to the consultant before the clinic appointment, which contributed to safe and well-coordinated care.

The national CQC maternity survey showed an increasing score of 6.8 out of 10 for whether women had received enough information to help decide where to have their baby. Providing postnatal information scored 7.6, feeding advice 7.2 and checking the baby’s health and progress 7.9.

Staff scheduled urgent scans to ensure these were completed within required timescales and booked women into the nearest hospital site, including York, Malton, or Bridlington, to support timely assessment and safe clinical decision making.

The service planned and delivered women’s care and treatment with them, including what was important and mattered to them. Care and treatment were delivered in line with legislation and current evidence based good practice and standards.

Staff had access to up to date clinical pathways aligned with national guidance, and key clinical documentation, risk assessment templates and visual prompts were displayed across wards to support consistent practice.

Clinical guidance was regularly reviewed and updated to meet National Institute for Health and Care Excellence (NICE) standards, national guidance, or best practice. For example, this included updates to the early postnatal baby assessment process and diabetes management pathways.

New guidance was shared with staff, demonstrating the service’s commitment to delivering evidence based care. Posters displayed updated information on maternity and neonatal operational pressures escalation and the associated escalation plans.

Women reported skin to skin contact with their baby was provided shortly after birth, demonstrating staff followed national guidance to promote early bonding and postnatal wellbeing.

Staff used the Modified Early Obstetric Warning Score (MEOWS), a nationally recognised tool to identify women at risk of deterioration, and escalated concerns appropriately. The new version of the national MEOWS tool is due to be launched in September 2026 once staff have completed the relevant training.

A clear maternity escalation policy for deteriorating women and babies was in place, and staff followed the agreed escalation pathways to ensure timely assessment and safe decision making.

The service now incident reported on primary post‑partum haemorrhage (PPH) equal to or greater than 1500ml which was in line national guidance for the prevention and management of postpartum haemorrhage.

Specialist midwives were dedicated to their specific roles and were not routinely allocated to clinical work. The service had leads in safeguarding, quality and patient safety, fetal monitoring, digital, and education. Their dedicated presence improved visibility and ensured they could focus on delivering specialist expertise and driving service improvement.

Care records consistently demonstrated clear documentation of assessment, evaluation, and care planning. Staff assessed and managed pain appropriately in line with national guidance and individual need.

Staff followed the required assessments and monitoring pathways, including blood glucose reviews, checks, growth scan schedules and referral to specialist or obstetric led care when indicated. These steps ensured women received safe, evidence based care in line with national guidance.

Staff protected the rights of women subject to the Mental Health Act and followed the Code of Practice.

The service showed 100% compliance in offering the respiratory syncytial virus (RSV) vaccine to pregnant women between 28 and 36 weeks gestation as per national recommendations, and information was available to support women considering the vaccine.

The service had strengthened its specialist midwifery roles, including an audit midwife, a dedicated Perinatal Mortality Review Tool (PMRT) midwife and plans to recruit an ATAIN midwife.

The service planned to develop an action plan to support required improvements to achieve compliance with the national bereavement care pathway, which will be incorporated into the single improvement plan for oversight and monitoring.

The evidence showed an exceptional standard.

The service demonstrated effective multidisciplinary team (MDT) collaboration with clear evidence of outstanding teamwork and collaboration across all roles and specialities. Staff worked together exceptionally well to benefit women, supporting one another to deliver safe, high quality, and compassionate care.

Managers held regular structured MDT meetings that promoted cohesive working, shared learning and collaborative decision making.

Attendance at handovers, safety huddles and ward rounds varied appropriately by speciality, ensuring the right staff were present, with multidisciplinary input from medical and midwifery staff, anaesthetists, and theatre teams.

Staff described close working with anaesthetists and other teams, which supported coordinated care and a cohesive multidisciplinary approach fully embedded in daily practice.

We observed excellent communication and coordination between staff of all roles and grades, and staff spoke positively about the strong culture of teamwork. Community midwives consistently worked in pairs, which supported safety and mutual support in practice.

New starters described the environment as calm and supportive, with one saying, “I feel very calm here,” reflecting a well embedded culture of team based working.

Patient information was shared promptly and effectively, ensuring continuity of care.

Medical and midwifery handovers between wards used structured and detailed multidisciplinary communication in a situation, background, action, and result (SBAR) format.

Students reported feeling fully supported by the service. They were invited to attend team meetings so they felt part of the wider team, and learning opportunities were consistently highlighted to them. This contributed to a positive learning environment and helped students develop confidence and competence in practice.

The maternity staff survey recorded an increased score of 6.3/10 for “we are a team”.

Staff told us they could easily contact medical staff when needed and that medical teams responded promptly, supporting effective multidisciplinary working.

The service supported women to manage their health and wellbeing effectively.

Staff promoted healthy lifestyles and provided practical advice and support.

Personalised care plans included information on a wide range of ways women could lead healthier lives, covering pelvic health and wellbeing, positive lifestyle changes such as healthy eating and staying active, and support to stop smoking. The plans also reinforced recommendations not to drink alcohol or use illegal drugs during pregnancy, helping them make informed choices to protect their health and their baby’s wellbeing.

Leaflets, posters, and display boards promoted healthy living and signposted women to local and national support services and charities. Myth busting posters addressed common health concerns, including incontinence and breastfeeding, supporting access to clear, evidence based information and promoting health education within the maternity environment.

Healthier lives advice was discussed at booking and at subsequent antenatal contacts, with all conversations documented on the digital system. This ensured consistent reinforcement of key public health messages and provided a clear record of the support offered throughout pregnancy. Where additional needs were identified, staff made timely referrals to dietitians and mental health teams, ensuring women received targeted specialist support alongside routine health promotion.

The service routinely monitored women’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of women.

Staff participated in national clinical audits and used the findings to improve care including the National Diabetes Maternity Audit.

The National Maternity and Perinatal Audit showed higher than average unplanned maternal readmission, induction of labour and episiotomy rates, and leaders developed a targeted improvement programme in response.

The most recent MBRRACE UK report showed mortality rates were similar to or lower than comparable services, and all maternal and neonatal deaths were reviewed through governance processes.

Staff used the Modified Early Obstetric Warning Score (MEOWS), which is a nationally recognised tool to identify women at risk of deterioration, and escalated concerns appropriately. CQC reviewed a recent audit completed for MEOWS. Staff undertook all observations on time, and they calculated 90% of them correctly.

A national maternity clinical dashboard was used to benchmark performance.

The service was no longer an outlier for PPH at 1500ml or more. In March 2026, the rate of PPH at 1500ml per 1000 births was 2.6%, within the expected Yorkshire and Humber range of 2% to 4%. The rate of PPH over 1500ml was 4.6% and required continued monitoring. A quality improvement project had been completed, and all women now receive a PPH risk assessment at 36 weeks and again on admission to the labour ward.

Clinical Quality Improvement Metrics for January 2026 showed mixed performance, with two areas requiring improvement including babies readmitted under 30 days and babies with an APGAR score between 0 and 6.

Antenatal and newborn screening performance was good, although some screening blood samples, newborn physical examinations and data capture processes required improvement. The service had developed a business case to increase ultrasound capacity in line with the Saving Babies Lives Care Bundle, ensuring timely access to surveillance for women with risk factors and meeting rising clinical demand.

The service had made progress on four of the six elements of the Saving Babies Lives Care Bundle V3.

The service had an extensive clinical audit plan with clear leads and electronic dashboards. A spotlight audit work plan for 2026 to 2027 ensured focused reviews across key areas such as scanning, induction of labour, medicines management and maternity triage.

Digital midwives checked audit data for accuracy, corrected errors and ensured findings were acted on.

Monthly ward assurance audits showed variable compliance with all inpatient wards below and antenatal outpatients above 95% target and leaders took action to strengthen accountability and improve performance. Weekly clinical and environmental audits also showed mixed performance between 75% and 100% against an 85% target, and some staff were not aware of audit outcomes.

Specialist teams completed their own clinical audits.

Fetal monitoring audits showed variable compliance, and leaders introduced a new audit tool and action plan to strengthen monitoring and data quality. Intrapartum risk assessment completion remained high, and the Focus on Fresh Eyes campaign was launched to improve holistic assessment and documentation.

Community audits showed women were booking their antenatal appointments later than expected, often at 12 weeks rather than the recommended 10 weeks, and work was planned with GP practices to encourage earlier booking.

Safeguarding audits showed very strong compliance with routine domestic abuse enquiries.

Staff completed thematic reviews when required, including a recent review of postpartum haemorrhage.

Quarterly ATAIN audits were undertaken to reduce avoidable neonatal admissions, with fluctuating performance.

The service audited Birmingham Symptom Specific Obstetric Triage (BSOTS) as part of its governance programme. Actions included allocating a consultant lead, reviewing medical staffing against Royal College of Obstetricians and Gynaecologists guidance, implementing the OPEL score and escalation pathway for triage, and undertaking a health check.

The service reported all maternal and neonatal deaths.

Women had access to their maternity notes via an electronic app, allowing real time access to information and enabling them to add allergies, birth plans, and feedback about their care.

Staff supported patients to make informed decisions about their care and treatment and followed national guidance to gain women’s consent.

Women participated in decision making, and staff provided all information required and offered choices according to their needs.

Consent was clearly documented in care records for all procedures and examinations.

During ward rounds there was a clear emphasis on ensuring women gave informed consent, and we observed staff respectfully seeking verbal consent before examinations, treatments, or personal care.

Staff demonstrated positive examples of shared decision making and showed a strong understanding of consent requirements.

Midwifery staff received basic Mental Capacity Act (MCA) training, and compliance was 85% close to the trust target of 90%.