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 and this improved to good at this assessment. This meant women’s needs were met through good organisation and delivery.

We looked for evidence that women were always at the centre of how care was planned and delivered. We checked that the health and care needs of women were understood, and they were actively involved in planning care that met these needs. We also looked for evidence that women could access care in ways that met their personal circumstances and protected equality characteristics.

In this assessment we found a new breach of Regulation 16 – Receiving and Acting on Complaints.

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 service made sure women were at the centre of their care and treatment choices and they decided, in partnership with staff, how to respond to any relevant changes in their needs.

Staff understood what mattered to women, provided care that met their physical, emotional, and social needs, and supported them and those close to them to understand their pregnancy and make decisions about their future care, birth options, and delivery.

We observed staff consistently delivering person centred care and meeting fundamental care needs. Staff ensured women understand their pregnancy care and treatment, providing clear information at every appointment and contact. Family and friends feedback included comments such as “you took the time to answer our questions in detail,” reflecting clear communication and a compassionate, person centred approach.

Women said they felt comfortable approaching staff, asking questions and felt listened to when they raised concerns and received helpful reassurance. Staff explained risks, screening options and test results in a way that was easy to understand, supporting informed decision making and enabling them to choose their preferred place of birth.

Most women told us their emotional and psychological wellbeing was checked regularly, and staff checked on their comfort and their baby’s wellbeing while on the postnatal ward. This helped women feel supported and reflected person centred postnatal care. Women also gave positive feedback about food quality and said they had access to a well-stocked kitchen for snacks and drinks outside mealtimes, which they found reassuring during unplanned visits.

Women had access to all their maternity records and were able to update these via the electronic system with personal requests and needs.

Staff, including community midwives and colleagues from other hospitals, could refer to a cross site team of specialist bereavement midwives. The team provided support on the delivery suite, in clinics, through follow up phone calls and home visits. They shared positive examples of supporting women, including those with pregnancies after previous losses, to attend their antenatal screening appointments, reflecting sensitive and person centred support.

Leaders described targeted work with local partners to reduce teenage pregnancies, improving access to appropriate services for young people and supporting more personalised care for this group.

A proportion of women felt their pregnancy had been monitored closely and appropriately. However, two women reported needing to chase testing appointments and blood results, highlighting occasional gaps in timely follow up and communication.

The service understood the diverse health and care needs of women and their local communities, so care was joined up, flexible and supported choice and continuity.

Most women confirmed they had a named midwife and found it easy to contact them when needed.

The service operated under a block contract that did not take account of fluctuations in demand or the increasing acuity of women and babies. In addition, staff told us this meant the service was often providing more than the two allocated scans per woman to meet clinical need and sometimes needed to seek support from other local hospitals when capacity or acuity pressures increased.

Staff provided antenatal and postnatal care to women in prisons and in “Safe City asylum accommodation,” ensuring equitable access to maternity services for people living in non-standard or vulnerable settings.

The community midwifery team’s relocation to a new hub in the centre of town was expected to improve equity of caseload allocation and strengthen continuity of care.

Staff worked with local authorities and social services to coordinate pre discharge arrangements for women with additional needs, ensuring timely information sharing and appropriate support.

Staff described effective cross site working and clear communication pathways that supported continuity when women required care at different points in the local maternity system.

The service developed appropriate, accurate and up-to-date information in formats that were tailored to individual needs and the new personalised care plan demonstrated a level of design, accessibility, and completeness that staff described as exemplar practice.

Women reported they had enough information to make decisions about their care, including their birth plan, and described feeling actively involved in decisions throughout their pregnancy.

Women could access patient information leaflets via QR codes directly from their personalised care plan or app, supporting timely access to their own maternity information and condition specific information. Staff consistently described the plan as an outstanding resource that offered extensive, high quality information in one place and allowed women to choose their preferred language and preferred communication method.

The service had produced the personalised care plan in collaboration with the MNVP, and it acted as a live information tool that was updated with birth planning choices to support shared decision making and continuity of care. This level of personalised, accessible, and comprehensive information provision exceeded the standard expected of a good service and demonstrated features characteristic of outstanding practice, particularly in the design and functionality of the personalised care plan.

Safety boards, posters, and leaflets across the service also displayed key information such as access to breastfeeding support available in local libraries. However, only around half of the antenatal women we spoke with said they had been offered information about antenatal classes, workshops, and support groups, indicating some variation in access to antenatal information.

Women could also view a discharge video online before going home and continue to access it after discharge, supporting consistent and accessible postnatal information.

Staff had access to clinical guidance and standard operating procedures to support safe and consistent care delivery.

We observed staff fully explaining procedures to women, ensuring they understood what would happen and why. This supported informed decision making and demonstrated clear communication practice.

Staff explained to women when homebirth provision was unavailable and offered alternative care options.

The service did not always make it easy for people to raise complaints about their care, treatment and support and did not meet the trust’s target for responding to complaints.

The 2025 CQC maternity survey showed women scored 6.8 out of 10 for considering making a complaint about the care they had received.

Visibility of information on how to contact the Patient Advice and Liaison Service required strengthening as no posters were observed in patient areas.

Only 9 of 20 complaints were closed within 30 working days, meaning just 45% met the target for standard complaints.

We did not receive data on performance for complex cases and monthly data showed a continued variance in the number of complaints that remained open across the year.

The service had 6 open complaints, with 3 overdue beyond the 30 day target. There were also 4 open complex cases, with 2 overdue beyond the 45 day target.

These findings showed the trust was not consistently meeting required response timeframes and was in breach of Regulation 16 - Receiving and Acting on Complaints which requires an effective and timely system for identifying, receiving, recording, handling, and responding to complaints.

A weekly meeting was in place to oversee progress against response timeframes and support investigating officers.

Complaints most commonly related to delays in recognising and responding to established signs of labour, communication and conflicting information and all complaints were reviewed with action plans put in place to support improvement.

The service kept in contact with complainants throughout the process, and when trust timeframes could not be met, staff apologised and agreed a revised response date.

Staff listened to women and their families and used feedback, concerns, and complaints to improve the service.

The service had a strategic approach to improvement with four defined workstreams, including one focused on listening to and working with women and families, led jointly by the transformation lead midwife and the MNVP.

Themes from compliments included kindness from staff, caring attitudes, compassion shown to women and families and good communication during pregnancy.

The 2025 CQC survey showed the service was rated within the expected range when compared with other NHS maternity providers. Antenatal care, labour and birth, care on the ward after birth, and postnatal care at home were all within the expected national range. The survey highlighted stronger performance in postnatal mental health screening, postnatal follow up and access to feeding advice. It identified weaker performance in early labour contact and postnatal ward experience, including advice at the start of labour, partner presence, concerns being taken seriously, and pain management. The findings aligned with known system pressures and existing maternity improvement priorities.

The service reached out to women as part of the Baby Friendly Initiative to record their experiences through a telephone survey. This enabled the service to benchmark against the standards for infant feeding and relationship building.

Staff provided examples of recent learning and changes in practice following a patient complaint.

Staff engaged positively with women about future home birthing provision, ensuring their views and experiences informed ongoing service planning.

Managers gave examples of seeking staff views on proposed changes, such as consulting the team on the positioning of new furniture, demonstrating active involvement in shaping the environment and contributing to service improvements.

Governance boards throughout the service displayed service improvements based on listening to patients.

The service recorded compliments with themes including kindness, caring attitudes, compassion, and good communication during pregnancy, supported by thank you cards and messages displayed in patient facing areas.

The service made sure that women could access the care, support, and treatment they needed when they needed it.

The service covered areas with high levels of deprivation and extensive rural and coastal communities, creating varied and complex access needs. The community midwifery team provided support across Bridlington, Scarborough, Malton, and Whitby through local hubs, offering on call home birth provision, postnatal visits, breastfeeding drop-ins, and wider community based care.

Community midwives told us that local arrangements in some GP practices meant they could only see women registered with that practice, creating variation in access. Pathways were adapted to ensure women continued to receive timely care, and the team was moving to a centrally located hub to support more consistent and equitable access.

Community leaders booked women who breached the 10 week antenatal booking timeframe into weekend clinics to ensure timely assessment and completion of screening tests within recommended timeframes. This formed part of the service’s wider safety netting approach.

Staff received and triaged referrals for the routine 12 week ultrasound scan directly from GP practices following clear criteria. They arranged further scans and coordinated associated clinical reviews, including consultant led clinics and specialist pathways. Staff scheduled urgent scans to ensure these were completed within required timescales and booked women into the nearest hospital site to support timely access.

Clinic appointments were rarely cancelled, as staffing arrangements ensured sessions were covered when needed.

Staff monitored and took action to minimise missed appointments. They followed a clear process to contact women who did not attend and offer new appointments. Community midwives offered to visit women at home who persistently missed their appointments and provided support or telephone consultations where appropriate. This demonstrated a proactive and flexible approach to maintaining engagement and reducing barriers to care.

The service introduced a weekly respiratory syncytial virus (RSV) vaccination clinic within the antenatal department because some GP practices were not offering community provision. Community midwives encouraged uptake from 28 weeks of pregnancy onwards, ensuring women continued to have timely access to preventative maternity care.

Referral to Treatment Time is the national measure of how quickly patients start consultant led treatment within 18 weeks, and performance for the obstetric specialty was 75%, which was below the national standard of 92% and showed women were waiting longer than expected to begin treatment.

A health inequalities audit identified barriers to attendance for hip scan appointments, including limited clinic availability at Scarborough, the absence of a text reminder system and the lack of a formal review process once scans were completed. This was shared with the screening quality assurance service and an action plan was in place.

Staff and leaders actively listened to information from women at risk of inequality and tailored care and support accordingly.

The clinical strategy stated “As we develop new models of care delivery, we will take an equity driven approach that recognises the barriers faced by many in our communities, such as of digital poverty, low levels of literacy and social isolation. We will adapt our delivery methods to ensure no one is left behind.”

Equity in experience and outcomes was embedded into the maternity and neonatal single improvement plan. Completed actions included a baseline review of patient information accessibility, the introduction of easy read guides and personalised care plans.

Future priorities focused on improving inclusion by reviewing support for women who may need help to access information digitally, and co-producing with women to ensure information was available in the top ten local languages.

Leaders explained that the geographical area did not have a large ethnically diverse population, but they recognised the need to strengthen teaching on cultural competence. This included ensuring staff were confident in recognising conditions such as jaundice in different skin tones.

Leaders described further planned actions to strengthen equity, including meeting accessibility standards for patient information and developing medium and long term estates plans.

The service had introduced two equity midwife roles to improve personalised support for women at increased risk of experiencing health inequalities and to provide responsive and inclusive care that offered continuity for women with additional needs. They delivered antenatal care to teenage pregnancies, asylum seeking women and women in prison, reducing the need for women to travel to the hospital, and supporting more inclusive and accessible care.

Compliance with equality, diversity and human rights training met the trust’s 90% target, demonstrating a positive organisational commitment to inclusive and equitable care.

Future priorities in the improvement plan focused on strengthening equity by implementing learning from the perinatal equity and antidiscrimination programme, reviewing the role of the community midwife for equitable health services, and completing a thematic review to ensure asylum seeking women receive safe, personalised, and equitable care.

The service supported women to plan for important life changes, so they have time, information, and support to make informed decisions.

ReSPECT training compliance was close to the trust’s 90% target, reflecting a positive organisational commitment to personalised emergency care planning.

A bereavement team was in post to support women following the loss of a baby, including during subsequent pregnancies, and work was underway to develop a specialist clinic to provide enhanced support for families in future pregnancies after loss.

Staff worked closely with chaplaincy, mortuary services, and the trust bereavement service to ensure families received coordinated and compassionate care. A dedicated bereavement room was available for women experiencing late pregnancy loss, stillbirth, or the loss of a baby shortly after birth.

Written guidelines and patient information were in place to support staff and women, including guidance on the management of stillbirth and early neonatal death and information for parents taking their baby home after loss. Leaflets were available in different languages.

Teaching sessions had been delivered to departments managing early pregnancy loss outside maternity services to support a consistent standard of bereavement care.

The bereavement team worked closely with the MNVP and the quality and patient safety midwives to ensure that review meetings and learning forums reflected the voices and experiences of bereaved families. This supported meaningful involvement in service learning and improvement.