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Friarage Hospital

Provider South Tees Hospitals NHS Foundation Trust Type NHS Healthcare Organisation Region Yorkshire & Humberside Last inspected 19 Jan 2024

Location rating: Good  View location on CQC

Location ratings by domain

Five CQC key questions

Ratings held for this CQC location under the inspection framework, last inspected 19 January 2024. Ratings extracted from individual reports are shown separately below.

Safe
Good
Effective
Good
Caring
Good
Responsive
Good
Well-led
Good

Most recent report indexed for actions

The date and rating here are from an individual report, not necessarily the location's latest assessment. Report ratings are extracted with AI; verify the original PDF.

Type: Location
Date: 19 January 2024
Rating extracted from this report: Good
Actions indexed: 2 must-do 4 should-do

Read this inspection PDF

AI-extracted 2 Jun 2026

Earlier inspection findings

pre-2024 framework · 2 must-do 4 should-do

Must-do actions (2)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 2
Must do
Well-led
The service must ensure there is a process to ensure oversight and management of policies, guidance and procedures to ensure they are reviewed in a timely manner, are clear and reflect national guidance
Regulation: Regulation 17(1)(2)(a)
⚠ The Clinical Effectiveness and Education group (CEEG) did not have an effective process to monitor policies and review dates, resulting in some guidelines (e.g., water birth, suitability for birthing checklist, midwifery-led care policy) being out of date, not reflecting best practice, or containing incorrect criteria.
Must-do action 2 of 2
Must do
Well-led
The service must ensure they have regular audit to demonstrate compliance with standards and procedures, to identify gaps, implement and monitor improvement
Regulation: Regulation 17(1)(2)(a)(b)
⚠ There was no regular audit of transfer times or outcomes from Friarage Maternity Centre (FMC) to James Cook University Hospital (JCUH), nor of conversations with women about transfer risks. Additionally, there was no audit of advice-line calls to determine diversions to JCUH, the impact on callers, or the management of …

Should-do actions (4)

Recommended improvements to enhance service quality.

Should-do action 1 of 4
Should do
Well-led
The service should consider the need for a separate risk register for the Friarage Maternity Centre
Should-do action 2 of 4
Should do
Well-led
The service should consider separating data collection from the James Cook University Hospital and use this to drive improvements.
Should-do action 3 of 4
Should do
Well-led
The service should consider how they can raise the profile of the Friage Maternity Centre.
Should-do action 4 of 4
Should do
Well-led
The service should consider how they improve the model of care to ensure it is fit for purpose.