Scarborough Hospital

On this page

• 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 inadequate and this improved to good at this assessment.

This means we looked for evidence that service leadership, management and governance assured high quality person centred care, supported learning and innovation, and promoted an open fair culture.

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of women who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person centred and sustainable and to reduce inequalities.

The service had strengthened its governance and risk management processes since the last inspection, with clearer oversight, more consistent monitoring, and improved systems to assess and mitigate risks, which meant it was no longer in breach of Regulation 17 - Good governance.

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 service had a shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

This vision was supported by a clear improvement plan aligned to the NHS three year delivery plan for maternity and neonatal services, developed with input from staff.

Engagement was central to the improvement journey, with colleagues, service users and system partners helping to shape priorities. Senior leaders held engagement events to promote psychological safety, listen, and turn feedback into actions. The improvement plan was created through this process, with workstreams aligned to national priorities.

The strategic approach was centred on the Maternity and Neonatal Services Delivery Framework, which sets out how issues were addressed through operational clinical delivery, quality, safety and governance and service improvement, with women’s experience at the centre.

Staff described a significantly improved culture.

Leaders recognised the importance of visibility, communication, and supportive leadership to sustain progress and strengthen trust. They used a range of communication methods, including daily huddles, newsletters, informal debriefs and brief updates during walkabouts, to ensure key messages were shared consistently across teams. To maintain communication, leaders also used staff welcome and governance boards, safety briefs, ad hoc debriefs and quarterly off site engagement days, and matrons planned to refresh ward meetings once core staff had settled into their designated areas to strengthen communication and consistency.

Senior leaders gave examples of staff collaborating on decisions such as how to allocate staffing related funding at the clinical frontline, demonstrating shared direction, collective ownership of improvement and a culture where staff contributions shaped service development.

Senior leaders had attended a culture and leadership programme.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders demonstrated integrity, openness and honesty, and staff described a significantly improved culture since the last inspection.

The senior leadership team had strengthened considerably, and staff consistently praised the director of midwifery for their visible presence and supportive leadership style. A new deputy director of midwifery was due to start, and recruitment was underway for the head of midwifery post, meaning two senior roles were not yet fully appointed into and the leadership team was still embedding. The service had also appointed a transformation lead midwife to support improvement work.

Leaders described strong support from trust management teams. The clinical director, who worked across both sites was described as approachable, open, and honest with a clear vision for the service.

Managers and matrons, including those working across both sites were consistently visible and approachable. Staff reported feeling well supported by their immediate line managers, who were accessible and responsive to day to day concerns.

Senior leaders acknowledged some staff needed time to rebuild relationships and confidence, and they recognised that small pockets of the workforce did not yet feel fully engaged.

Previous leadership instability, including the appointment of a fifth director of midwifery in four years, had contributed to uncertainty, but leaders now demonstrated a more consistent approach to visibility, communication, and supportiveness to sustain progress and strengthen trust.

Staff told us face to face meetings were not yet embedded and communication could still be inconsistent. Leaders described challenges with attendance at departmental meetings due to shift patterns, staffing pressures, and practical barriers such as parking costs.

Leaders attended annual planning days to discuss priorities, risks, and aspirations for the service. There was evidence of leadership support for workforce development, including succession planning and access to training opportunities such as coaching programmes and complaints management courses.

Staff had a clear understanding of their roles, responsibilities and reporting arrangements, and the service provided opportunities for staff to develop their skills and progress into more senior roles.

The integrated care board noted remaining gaps in senior leadership but was assured that recruitment was progressing as part of the three year maternity and neonatal support plan. Leaders met regularly with the integrated care board to review progress against the support plan, including leadership recruitment and workforce development priorities, demonstrating shared oversight and a coordinated approach to improvement.

The service did not always foster a positive culture where people felt they could speak up and their voice would be heard.

Most staff we spoke with were not aware of the trust’s freedom to speak up service, and some did not know who the guardians were or how to contact them. This indicated gaps in the visibility and communication of the freedom to speak up offer, despite systems being in place to support speaking up.

The annual report presented to the board in 2025 showed a continued reduction in concerns raised by staff through this process over the last three years. The report said this could reflect reduced engagement, resolution of previous concerns, barriers to speaking up or increased confidence in raising issues directly with line managers.

The maternity staff survey recorded an increased score of 6.3/10 for “we each have a voice than counts”.

We observed information displayed about the freedom to speak up service in antenatal clinical areas, although this was not visible elsewhere in the maternity service. This meant visibility of the offer was inconsistent across clinical areas.

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

The service valued diversity in its workforce and worked towards an inclusive and fair culture by improving equality and equity for people who worked there.

Midwives new to community roles were offered a structured period of support to build confidence, with an experienced community midwife available alongside them for home births until they felt confident to undertake the role independently. This helped ensure equitable access to development and safe practice.

The trust had organisation wide equality, diversity and inclusion objectives and monitored performance against national standards, with action plans and staff networks in place to support an inclusive working environment.

The trust had active staff networks, including carers, race equality, disability, women’s, and LGBTQ plus networks, which provided peer support and raised awareness of diverse needs across the organisation. These networks contributed to a culture where staff felt represented, supported, and able to share their experiences.

The service had clear responsibilities, roles and systems of accountability, and governance processes were now operating more effectively than at the last inspection. Leaders acted on the best information about risk, performance and outcomes and shared this securely with others when appropriate. This reflected significant improvement since the previous breaches of Regulation 17 - Good Governance.

The service now had formalised governance structures and processes from ward and department level through to the family health care group board. Regular multidisciplinary assurance meetings supported oversight, shared learning, and accountability across clinical teams.

A maternity dashboard summarised performance across key metrics. Significant work had gone into creating a comprehensive improvement plan, with a clear live action plan relating to each workstream with expected end dates and reviews against national standards. These were monitored through service and board level committees, including the Maternity Assurance Group. Minutes from regular cross site meetings showed strengthened oversight, clearer scrutiny and more consistent follow up than previously.

The Maternity Assurance Group also reviewed quality and safety metrics, complaints, safety events, staff engagement, training compliance, staffing levels, and service diversions.

Governance boards across clinical areas displayed progress.

The maternity outcomes signal system triggered two alerts in late 2025 and early 2026, which were reviewed by the local MNVP and found to require no additional actions beyond the existing improvement plan.

The service oversaw governance of national programmes including the maternal care bundle, Saving Babies Lives and the maternity incentive scheme, with named leads identified for each area.

Risk recognition, escalation, and management had improved. Incident reporting was more structured, and learning from incidents and complaints was embedded through case reviews and multidisciplinary learning. Risks were managed in line with the trust risk management strategy and overseen through directorate, care group, and trust level committees.

The service had a clear decant plan during planned roof replacement works that included reducing elective activity, activating the maternity escalation policy, and seeking mutual aid from neighbouring providers to maintain safe capacity and continuity of care.

The service acknowledged weaknesses in mandatory training governance and outlined actions to strengthen oversight. This included engaging with the national review of training, introducing training passports and establishing an oversight group. Plans were in place to move to a “train once and maintain competence” through practice approach to simplify requirements and increase protected time for staff.

Despite using multiple digital systems, staff used these effectively to book scan appointments, share information and coordinate care across sites. Limitations in digital reporting were mitigated through monthly establishment reviews with finance to ensure accurate workforce information.

Leaders had clear oversight of the environmental and workforce constraints affecting obstetric theatre activity and monitored these risks through governance meetings, incident reviews, and safety huddles. They recognised that improvements were required to strengthen compliance with national peri-operative standards. These issues remained under active review and were included in the service’s improvement plan.

The service understood its duty to collaborate and work in partnership so services worked more seamlessly for women.

The service demonstrated a well-established network of partnerships with stakeholders that supported coordinated care, strengthened community engagement, and ensured women’s experiences directly informed improvement work.

The service had regular quarterly meetings with women, councils, Healthwatch and volunteer groups sharing information such as staffing, estates, and quality improvements.

The service had strengthened collaborative working with the MNVP to co-design engagement activity, create a service user engagement plan and strengthen community involvement to ensure women’s voices shaped priorities and improvement work.

They discussed feedback from MNVP visits, launched bespoke surveys, and held focus groups to understand what was working well, what could be improved and issues raised by women.

MNVP posters were displayed in antenatal areas to signpost women to provide independent feedback.

This collaborative approach supported shared decision making, improved transparency and demonstrated a mature and effective partnership with the local maternity and neonatal voices group.

The service introduced “Whose Shoes” to strengthen engagement with women and families.

Staff promoted coordinated care with local authorities, social services, health visitors, and local agencies, particularly for discharge arrangements for women with additional needs.

Community midwives gave positive examples of working with local organisations to support women with practical or social needs through established local contacts with strong knowledge of local information and resources.

Safeguarding midwives worked in partnership with the City of York Council early help team, delivering masterclasses, including learning from a recent safeguarding review, to strengthen staff understanding of local safeguarding pathways and ensure consistent multi-agency working. They attended strategy meetings across all three local authorities and were involved in pre-birth planning, child protection processes, and discharge planning, ensuring coordinated safeguarding practice.

Digital systems allowed GPs and local hospitals to access women’s care records to support continuity of care and timely clinical decision making. Digital midwives worked with GPs to ensure the correct electronic forms were available for community midwives to use for referrals, supporting consistent information sharing and improved data quality. They also attended quarterly regional digital meetings, strengthening integrated working across organisations.

Staff described good communication with the local university.

Staff and leaders focused on continuous learning, innovation, and improvement, and were committed to developing new and creative ways to improve patient experience, outcomes, and quality of life.

The service participated in national audits and leaders described how they supported staff to contribute to improvement work and ensured teams had the time and resources to participate.

Quality improvement projects to strengthen active learning and improvement included induction of labour, acute scanning and planned caesarean birth, and staff could describe the aims, actions, and impact of these projects, which were supported by audits to monitor progress.

New quality improvement projects were developed after the service was identified as a national outlier in the 2025 CQC maternity survey. Key priorities included enabling birthing partners to support women throughout postnatal care outside standard visiting hours and strengthening pain management.

Service improvements were displayed across governance boards to increase visibility of learning and progress.

Women had opportunities to participate in university research, including the Snapshot Obstetric National Anaesthetic Research Project SONAR1 study exploring their experience and comfort during caesarean birth under regional anaesthesia.