Source · CQC inspection
The York Hospital
Provider York and Scarborough Teaching Hospitals NHS Foundation Trust
Type NHS Healthcare Organisation
Region Yorkshire & Humberside
Last inspected 2 Jul 2025
Overall rating: Requires Improvement View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Requires Improvement
Well-led
Good
Current CQC assessment
Requires Improvement
The service is not performing as well as it should and we have told the service how it must improve.
Ratings by service
Medical care (Including older people's care)
Requires Improvement
Urgent and emergency services
Requires Improvement
Medical care (Including older people's care)
Requires Improvement
Urgent and emergency services
Requires Improvement
Regulatory breaches & enforcement
Breaches identified (5)
Breach
Overall
The service remained in breach of these regulations at this assessment.
Breach
Safe
The service was in breach of regulations relating to safe care and treatment, premises and equipment and good governance as well as staffing.
Breach
Safe
While improvements had been made since the last assessment, we identified breaches of regulation in relation to safe care and treatment, and premises and equipment.
Breach
Overall
Whilst the service had improved in a number of places since the last assessment at this assessment we still found breaches of legal regulations.
Breach
Overall
At the last assessment the service was in breach of the legal regulations relating to person centred care and safeguarding.
Earlier inspection findings
Must-do actions (95)
Must-do action 1 of 95
Must do
Well-led
The trust must seek and act on feedback from relevant persons on the services provided, for the purposes of continually evaluating and improving such services.
Must-do action 2 of 95
Must do
Well-led
The trust must ensure the organisations supports all staff, including those with particular equality characteristics, to feel respected and valued and supports an environment where staff are encouraged to speak up and raise concerns without fear of blame or reprisal.
Must-do action 3 of 95
Must do
Well-led
The trust must ensure that the guidance within all policies is up to date, accurate and relevant to the service. This includes, but is not limited to, the guidance within the workforce and equality, diversity, and inclusion (EDI), freedom to speak up, policies for transgender and non-binary people and unacceptable behaviours from patients.
Must-do action 4 of 95
Must do
Well-led
The trust must demonstrate its supports its staff by challenging unacceptable behaviours and language. This includes, but is not limited to, racism and discrimination.
Must-do action 5 of 95
Must do
Well-led
The trust must ensure it takes account of the Workforce Race Equality Standard, Workforce Disability Equality Standard and NHS staff survey data to ensure both staff from ethnic minority groups and disabled staff are not disproportionately disadvantaged by working in the organisation.
Must-do action 6 of 95
Must do
Well-led
The trust must ensure that structured case reviews are focussed on the implementation of recommended actions and the actions are monitored, completed, and recorded.
Must-do action 7 of 95
Must do
Well-led
The trust must fully investigate and seek to learn from the death of a person with a learning disability or autistic people including seeking LeDeR reviews.
Must-do action 8 of 95
Must do
Well-led
The trust must gain assurance that learning from incidents and risks are shared within the organisation to prevent the risk of reoccurrence.
Must-do action 9 of 95
Must do
Well-led
The trust must ensure that risks recorded at corporate level and in the board assurance framework are current, not duplicated and have clear actions for mitigation which can be monitored and measured.
Must-do action 10 of 95
Must do
Safe
The trust must ensure that high level risks, particularly in relation to estates are fully assessed and mitigated to the lowest level of risk.
Must-do action 11 of 95
Must do
Well-led
The trust must ensure there is an accountability framework for care groups to monitor performance on action plans or mitigating risk.
Must-do action 12 of 95
Must do
Well-led
The trust must ensure there is full clinical engagement to support operational performance and that challenges are resolved with a focus upon patient safety across the organisation.
Must-do action 13 of 95
Must do
Responsive
The trust must ensure that there is adequate oversight of the harms caused by delays to assessment and treatment.
Must-do action 14 of 95
Must do
Safe
The trust must ensure ongoing patient safety concerns such as falls, pressure ulcers and healthcare care acquired infections are addressed in a timely way and all possible actions are taken to address concerns.
Must-do action 15 of 95
Must do
Safe
The trust must ensure adequate action is taken following audits which identify medication storage issues.
Must-do action 16 of 95
Must do
Safe
The trust must ensure they are delivering fundamental standards of care and patients receives safe and effective care that meets their needs.
Must-do action 17 of 95
Must do
Responsive
The trust must ensure that complaints are responded to in a timely way, result in further investigation if indicated and where possible involve family in the investigation.
Must-do action 18 of 95
Must do
Safe
The service must ensure their new ED has sufficient side rooms for medical staff to see and treat patients, barriered isolation rooms for infectious patients, handwash basins and storage areas for equipment.
Must-do action 19 of 95
Must do
Caring
The service must ensure their new ED environment does not compromise the fundamental standards of care staff can provide to patients, protects their privacy and dignity, and ensures staff can offer them emotional support.
Must-do action 20 of 95
Must do
Safe
The service must review processes for ED staff completing full resuscitation trolley checklists to ensure all specialist live-saving equipment is stocked and in date in the event of an emergency.
Must-do action 21 of 95
Must do
Safe
The service must ensure ED staff accurately and consistently complete risk assessments for each patient on admission or arrival and review this regularly using appropriate screening tools (in which they are trained and familiar).
Must-do action 22 of 95
Must do
Safe
The service must ensure all patients in ED are wearing wristbands at all times for improved safeguarding, security and easier identification when prescribing and administering medications.
Must-do action 23 of 95
Must do
Safe
The service must ensure the service improves compliance in sepsis screening, especially for patients receiving antibiotics within an hour. They must also ensure ED medical staff improve their overall training compliance rate in sepsis screening and all ED staff complete screening for patients at risk of sepsis (to better recognise and respond to warning signs of deterioration).
Must-do action 24 of 95
Must do
Safe
The service must ensure staff do not place patients at higher risks such as those with IV access or allergies in inappropriate environments for their needs and observe them accordingly.
Must-do action 25 of 95
Must do
Well-led
The service must ensure ED staff maintain detailed records of patient’s care and treatment, so they are clear, up to date and stored securely.
Must-do action 26 of 95
Must do
Effective
The service must ensure ED staff fully and accurately complete patients’ fluid and nutrition charts and offer patients drinks, especially long waiters, and those in recovery.
Must-do action 27 of 95
Must do
Effective
The service must ensure ED nursing and medical staff training compliance in the mental capacity act (MCA) and deprivation of liberty safeguard (DoLS) meets trust target.
Must-do action 28 of 95
Must do
Well-led
The service must ensure executive, care group and operational leads and managers are responsive, supportive and take action when ED staff need help.
Must-do action 29 of 95
Must do
Safe
The service must ensure there are sufficient quantities of cardiotocography (CTGs), central monitoring and telemetry equipment. This was to ensure women and babies are continually assessed and monitored.
Must-do action 30 of 95
Must do
Safe
The service must implement an effective system to assess and monitor compliance to ensure the baby tagging process is adhered to in line with trust policy.
Must-do action 31 of 95
Must do
Safe
The service must ensure that mandatory training compliance, including core and role specific training meets the trust target. They must improve the compliance rates for theatre recovery training, practical obstetric multi-professional training and saving babies lives version 2.
Must-do action 32 of 95
Must do
Safe
The service must ensure they assess the risks during the triage process to ensure the health and safety of service users.
Must-do action 33 of 95
Must do
Safe
The service must ensure all staff are aware of and consistently follow the trust policy to safely store medicines including controlled drugs.
Must-do action 34 of 95
Must do
Safe
The service must ensure that the assessment of risk, preventing, detecting, and controlling the spread of, infections, including those that are healthcare associated is managed in line with trust and national guidance.
Must-do action 35 of 95
Must do
Safe
The service must ensure storeroom doors are not left open or unlocked and accessible to patients or members of the public.
Must-do action 36 of 95
Must do
Safe
The service must ensure both theatres are serviced, maintained, and fit for purpose in line with best practice guidance.
Must-do action 37 of 95
Must do
Safe
The service must ensure the maintenance of the theatre environment meets the national standards. They must ensure they are both fit for purpose, inspected yearly and actions instigated.
Must-do action 38 of 95
Must do
Well-led
The service must implement an effective system to assess, monitor, and drive improvement in the quality and safety of the services provided. They must demonstrate improvements in patient outcomes to be in line with national guidance and benchmark against a similar sized service.
Must-do action 39 of 95
Must do
Safe
The service must ensure fire risk assessments are up to date, thoroughly assessed and documented to meet best practice guidance. For example, they must ensure fire exits are clearly marked and have safe exit routes. They must ensure fire drills are completed regularly and audited.
Must-do action 40 of 95
Must do
Well-led
The service must implement an effective system to identify and report incidents including the severity of harm. The system must ensure incidents are appropriately reported to internal and external systems within appropriate timescales. The system must ensure incidents are effectively reviewed, lessons and actions are identified and shared with staff.
Must-do action 41 of 95
Must do
Well-led
The service must implement a robust governance process and risk management strategy. For example, they must ensure they instigate a process to effectively triage women in a safe environment. They must ensure they have effective risk management processes in place to manage and mitigate all risks.
Must-do action 42 of 95
Must do
Well-led
The service must ensure key environmental and clinical audits are completed and monitored with action plans. For example, audits on fresh eyes assessments and WHO safety checklists.
Must-do action 43 of 95
Must do
Safe
The service must ensure that there are enough midwifery and medical doctors to meet minimum staffing levels and they should mitigate against the risks of short staffing.
Must-do action 44 of 95
Must do
Effective
The service must ensure that persons employed receives such appropriate support, training, professional development, supervision, and appraisal as is necessary to enable them to carry out the duties they are employed to perform and be enabled where appropriate to obtain further qualifications appropriate to the work they perform.
Must-do action 45 of 95
Must do
Responsive
The trust must ensure that that care meets the needs of service users by improving referral to treatment times.
Must-do action 46 of 95
Must do
Effective
The trust must ensure that effective systems are in place to ensure staff adhered to the Mental Capacity Act.
Must-do action 47 of 95
Must do
Safe
The trust must ensure that all staff groups complete designated mandatory training sessions.
Must-do action 48 of 95
Must do
Safe
The trust must ensure that medical staff and additional clinical staff complete safeguarding training and PREVENT Awareness training sessions.
Must-do action 49 of 95
Must do
Effective
The trust must ensure that all medical staff have completed Mental Capacity Act and Deprivation of Liberty Safeguards training sessions.
Must-do action 50 of 95
Must do
Safe
The trust must ensure that all nursing and medical staff complete and are maintain adult life support and adult advanced life support training skills.
Must-do action 51 of 95
Must do
Effective
The trust must ensure that all staff receive annual appraisals.
Must-do action 52 of 95
Must do
Safe
The trust must ensure that all bank and agency staff had a full induction and competencies assessed prior to them working in the medical service.
Must-do action 53 of 95
Must do
Safe
The trust must ensure that controlled substances hazardous to health (COSHH) are always locked away.
Must-do action 54 of 95
Must do
Caring
The trust must ensure that mixed sex breaches where men and women share the same area did not occur.
Must-do action 55 of 95
Must do
Safe
The trust must ensure that where necessary patients have risk assessments completed and reviewed as per guidance employed.
Must-do action 56 of 95
Must do
Safe
The trust must ensure that time critical medicines are given when prescribed.
Must-do action 57 of 95
Must do
Safe
The trust must ensure that the patient's own medicines book is completed on admission and when the medicines are returned to them on discharge.
Must-do action 58 of 95
Must do
Effective
The trust must continue to ensure patients nutritional and hydration needs are met and this is confirmed through the Malnutrition universal screening tool (MUST) auditing process.
Must-do action 59 of 95
Must do
Well-led
The trust must ensure that the Freedom to speech up policy guidance (v11) which was passed its review date of February 2022 is updated.
Must-do action 60 of 95
Must do
Well-led
The trust must implement effective systems and processes to assess, monitor and improve quality and safety.
Must-do action 61 of 95
Must do
Well-led
The trust must ensure that all incidents are reported through the trust incident reporting system.
Must-do action 62 of 95
Must do
Well-led
The trust must ensure that patients records are maintained securely, are accurate, complete, and contemporaneous records maintained in respect of each service user.
Must-do action 63 of 95
Must do
Safe
The trust must ensure that there are sufficient allied healthcare professional, nursing, and medical staff to keep people safe.
Must-do action 64 of 95
Must do
Safe
The service must still ensure all ED medical staff comply with all aspects of their mandatory training and core specific training modules to meet trust target.
Must-do action 65 of 95
Must do
Caring
The service must ensure their new ED environment does not compromise the fundamental standards of care staff can provide to patients and protects their privacy and dignity.
Must-do action 66 of 95
Must do
Safe
The trust must review processes for ED staff completing full resuscitation trolley checklists to ensure all specialist live-saving equipment is stocked and in date in the event of an emergency.
Must-do action 67 of 95
Must do
Safe
The service must ensure ED staff know about and deal with any specific risk issues such as patients at risk of sepsis. They must complete patient’s sepsis 6 care bundle paperwork including medication administration times, patient details and follow up actions.
Must-do action 68 of 95
Must do
Safe
The service must ensure ED staff review national patient safety alerts for relevant learning and ensure measures taken around historical alerts are maintained.
Must-do action 69 of 95
Must do
Effective
The service must ensure service leads take action to improve their performance in the royal college of emergency medicine (RCEM) standards and develop a robust action plan from the 2020-21 results.
Must-do action 70 of 95
Must do
Effective
The service must ensure ED medical staff’s additional learning compliance in dementia and learning disabilities (LD) awareness meets trust target.
Must-do action 71 of 95
Must do
Effective
The service must ensure managers monitor the service’s use of Deprivation of Liberty Safeguards and ensure staff know how to complete them. Managers must also monitor how well the service follows the Mental Capacity Act and how they would make changes to practice when necessary.
Must-do action 72 of 95
Must do
Responsive
The service must ensure the service continues to work to improve the following performance standards at Scarborough hospital; the median time from arrival to treatment. the percentage of patients admitted, transferred, or discharged within four hours. the monthly percentage of patients that left before being seen.
Must-do action 73 of 95
Must do
Safe
The service must ensure that mandatory training compliance, including core and role specific training meets the trust target. They must improve the compliance rates for theatre recovery training, practical obstetric multi-professional training and saving babies lives version 2.
Must-do action 74 of 95
Must do
Safe
The service must ensure all staff are aware of and consistently follow the trust policy to safely store medicines including controlled drugs.
Must-do action 75 of 95
Must do
Safe
The service must ensure clean utility doors are not left open or unlocked and accessible to patients or members of the public.
Must-do action 76 of 95
Must do
Well-led
The service must implement an effective system to assess, monitor, and drive improvement in the quality and safety of the services provided. They must demonstrate improvements in patient outcomes to be in line with national guidance and benchmark against a similar sized service.
Must-do action 77 of 95
Must do
Safe
The service must ensure fire risk assessments are up to date, thoroughly assessed and documented to meet best practice guidance. For example, they must ensure fire exits are clearly marked and have safe exit routes. They must ensure fire drills are completed regularly and audited.
Must-do action 78 of 95
Must do
Well-led
The service must implement an effective system to identify and report incidents including the severity of harm. The system must ensure incidents are appropriately reported to internal and external systems within appropriate timescales. The system must ensure incidents are effectively reviewed, lessons and actions are identified and shared with staff.
Must-do action 79 of 95
Must do
Well-led
The service must implement a robust governance process and risk management strategy. They must ensure they have effective risk management processes in place to manage and mitigate all risks.
Must-do action 80 of 95
Must do
Well-led
The care group must ensure key environmental and clinical audits are completed and monitored with action plans. For example, audits on fresh eyes assessments and WHO safety checklists.
Must-do action 81 of 95
Must do
Safe
The service must ensure that there are enough midwifery and medical doctors to meet minimum staffing levels and they should mitigate against the risks of short staffing.
Must-do action 82 of 95
Must do
Effective
The service must ensure staff receive an annual appraisal.
Must-do action 83 of 95
Must do
Responsive
The trust must ensure that that care meets the needs of service users by improving referral to treatment times.
Must-do action 84 of 95
Must do
Caring
The trust must ensure that attendance to patient ‘fundamental care needs’ are met, including getting enough help to wash or keep clean and to eat meals, as well as being able to get help from staff when needed.
Must-do action 85 of 95
Must do
Safe
The trust must ensure that medical staff complete safeguarding training, PREVENT Awareness, Mental Capacity Act and Deprivation of Liberty Safeguards training sessions.
Must-do action 86 of 95
Must do
Safe
The trust must ensure that medical staff complete annual adult life support training.
Must-do action 87 of 95
Must do
Safe
The trust must ensure that all staff complete the mandatory training sessions relevant to their roles.
Must-do action 88 of 95
Must do
Effective
The trust must ensure that effective systems are in place to ensure staff adhered to the Mental Capacity Act.
Must-do action 89 of 95
Must do
Safe
The trust must ensure that all bank and agency staff had a full induction and competencies assessed prior to them working in the medical service.
Must-do action 90 of 95
Must do
Safe
The trust must ensure that controlled substances hazardous to health (COSHH) are always locked away.
Must-do action 91 of 95
Must do
Safe
The trust must ensure that where necessary patients have risk assessments completed and reviewed as per guidance employed.
Must-do action 92 of 95
Must do
Safe
The trust must ensure that there is sufficient space around patient beds, with oxygen and suction placed by every bed.
Must-do action 93 of 95
Must do
Well-led
The trust must ensure that patients records are maintained securely, are accurate, complete, and contemporaneous records maintained in respect of each service user.
Must-do action 94 of 95
Must do
Well-led
The trust must ensure the Care Group 2 risk register identifies all the current risks including none compliance to referral to treatment targets, consultant, and nursing staffing shortfalls.
Must-do action 95 of 95
Must do
Safe
The trust must ensure that there are sufficient allied healthcare professional, nursing, and medical staff to keep people safe.
Should-do actions (45)
Should-do action 1 of 45
Should do
Well-led
The trust should ensure that it follows the recommended period for repeating and recording Disclosure and Barring Service checks for directors.
Should-do action 2 of 45
Should do
Well-led
The trust should consider ensuring all recording and timelines for grievances and disciplinary processes are a complete and contemporaneous record.
Should-do action 3 of 45
Should do
Well-led
The trust should ensure clear levels of responsibility and accountability for management of staff not employed by the trust for example York Teaching Hospital Facilities Management (YTHFM) staff.
Should-do action 4 of 45
Should do
Well-led
The trust should consider increasing the frequency of safeguarding reporting to board to improve oversight.
Should-do action 5 of 45
Should do
Safe
The trust should consider recruiting looked after children specialist nurses to support capacity for initial health reviews.
Should-do action 6 of 45
Should do
Responsive
The trust should ensure it meets the criteria for accessible information standard (AIS).
Should-do action 7 of 45
Should do
Well-led
The trust should ensure disabled staff are protected in line with the Equality Act 2010 and have meaningful personal adaptation plans to ensure they are treated fairly; with dignity and respect they deserve.
Should-do action 8 of 45
Should do
Safe
The service should ensure all ED staff’s mandatory training modules are complete and compliance meets trust target, especially medical staff.
Should-do action 9 of 45
Should do
Safe
The service should ensure ED medical staff complete their required level of safeguarding training, especially for safeguarding children.
Should-do action 10 of 45
Should do
Safe
The service should ensure the IPC team and sepsis leads are better embedded and visible in the department to support staff with potentially infectious patients, assessments, or audits.
Should-do action 11 of 45
Should do
Safe
The service should review pharmacy CD inspection policy to ensure it is clear how often inspection should take place.
Should-do action 12 of 45
Should do
Safe
The service should review departmental processes for recording of controlled drugs to ensure all documents are completed in line with NICE guidance.
Should-do action 13 of 45
Should do
Effective
The service should ensure ED and SDEC staff offer patients in waiting areas enough to drink and eat. They should also ensure staff fully and accurately complete fluid balance and nutritional charts for patients.
Should-do action 14 of 45
Should do
Effective
The service should ensure midwifery staff complete their mentorship training to provide them the skills to facilitate preceptorship programmes to new students and newly qualified midwifes.
Should-do action 15 of 45
Should do
Well-led
The service should ensure all version-controlled documents are reviewed and in date.
Should-do action 16 of 45
Should do
Well-led
The service should ensure they can evidence the decision making and governance processes surrounding the use of balloon catheters.
Should-do action 17 of 45
Should do
Safe
The trust should ensure that cleaning records are completed in all clinical areas.
Should-do action 18 of 45
Should do
Safe
The trust should ensure that monitoring and action plans are in place should water checks and legionella checks fail.
Should-do action 19 of 45
Should do
Safe
The trust should ensure that equipment such as drip stands, and ceiling hoists were available on ward 23.
Should-do action 20 of 45
Should do
Safe
The trust should ensure that patients had venous thromboembolism (VTE) checks and risk assessments are completed and documented with in the current trust protocol within 14 hours.
Should-do action 21 of 45
Should do
Effective
The trust should ensure that patients on the acute stroke ward 23 received their daily 45 minutes of rehabilitation.
Should-do action 22 of 45
Should do
Effective
The trust should ensure that psychology services are made available for patients.
Should-do action 23 of 45
Should do
Well-led
The trust should ensure they achieve joint advisory group on gastrointestinal endoscopy (JAG) accreditation throughout the trust.
Should-do action 24 of 45
Should do
Responsive
The trust should ensure that consultants lead daily ward rounds on the emergency assessment unit to ensure patients are discharged and improve patient flow.
Should-do action 25 of 45
Should do
Responsive
The trust should ensure that patients discharge plans are commenced on admission to the service so that support is in place where needed on the patients discharge.
Should-do action 26 of 45
Should do
Well-led
The trust should consider introducing patient records and consent audits.
Should-do action 27 of 45
Should do
Well-led
The trust should consider introducing pain audits to gain assurance that pain services are improving patients' outcomes.
Should-do action 28 of 45
Should do
Safe
The trust should consider identifying dedicated rehabilitation and kitchen areas for use when undertaking patient assessments on the acute stroke ward.
Should-do action 29 of 45
Should do
Safe
The trust should consider that doors to rooms where medicines are stored are lockable and kept locked when not in use.
Should-do action 30 of 45
Should do
Caring
The trust should ensure that patient information on whiteboards remains confidential throughout the service and is not located in areas where the general public can see it.
Should-do action 31 of 45
Should do
Responsive
The service should ensure care group one compliance with closing complaints meets the trust target.
Should-do action 32 of 45
Should do
Safe
The service should ensure staff responsible complete legionella water testing daily as per their required schedule.
Should-do action 33 of 45
Should do
Safe
The service should ensure service staff are trained in sufficient numbers to recognise or respond to the warning signs of sepsis in patients.
Should-do action 34 of 45
Should do
Well-led
The service should ensure ED staff keep records for patients on trolleys waiting in the ambulance arrival corridor secure.
Should-do action 35 of 45
Should do
Safe
The service should ensure ED staff complete all sections of risk assessments for patients who show signs of mental ill health. They should consider revising this documentation’s length to improve staff compliance.
Should-do action 36 of 45
Should do
Safe
The service should ensure the service does not contravene their SOP for the care and treatment of patients whilst in an ambulance.
Should-do action 37 of 45
Should do
Responsive
The service should ensure ED staff recognise or make reasonable adjustments to meet patient needs such as those with mental health issues or anxiety.
Should-do action 38 of 45
Should do
Effective
The service should ensure midwifery staff complete their mentorship training to provide them the skills to facilitate preceptorship programmes to new students and newly qualified midwifes.
Should-do action 39 of 45
Should do
Safe
The service should ensure resuscitation trollies are checked in line with trust policy and records are available to evidence completion.
Should-do action 40 of 45
Should do
Well-led
The service should ensure they can evidence the decision making and governance processes surrounding the use of balloon catheters.
Should-do action 41 of 45
Should do
Well-led
The trust should ensure that safety huddle documentation is formalised across the service.
Should-do action 42 of 45
Should do
Well-led
The trust should ensure that staff receive feedback from incidents.
Should-do action 43 of 45
Should do
Well-led
The trust should consider introducing auditing of consent and patient records.
Should-do action 44 of 45
Should do
Safe
The trust should ensure that monitoring and action plans are in place should water checks and legionella checks fail.
Should-do action 45 of 45
Should do
Safe
The trust should consider that doors to rooms where medicines are stored are lockable and kept locked when not in use.