Huddersfield Royal Infirmary

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our last assessment, we rated this key question requires improvement. At this assessment the rating remained requires improvement. We found a continued breach of regulation in relation to ligature risks.

We identified additional breaches of regulation. These included concerns relating to infection prevention and control, such as poor bare‑below‑the‑elbow compliance and unsafe practice. Mandatory training compliance for medical staff was low across all modules.

This meant some aspects of the service were not always safe and there was limited assurance about safety.

We have not awarded this service a score for Safe.

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

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The urgent and emergency care (UEC) department monitored and reviewed all patient safety events resulting in severe harm or death through the trust risk management reporting software system, with learning responses commissioned in line with the Patient Safety Incident Response Framework.

The most common incidents included recognition and escalation of clinical deterioration, clarity of clinical responsibility for patients being reviewed by different speciality teams in the hospital and safe transfer processes and handover. We saw evidence of learning and improvements from these. For example, whilst we were on site a patient was prescribed the wrong insulin, we saw learning from this incident was shared including the importance of double-checking insulin prescriptions against pre-admission regimes and promoting awareness of time-critical medication guidance.

Staff had a good understanding of how to use the incident reporting system. Staff were aware of the key themes which had resulted from recent complaints and incidents and felt confident raising issues and concerns when they arose. Senior members of staff and leaders were involved in reviewing complaints and incidents. Reviews of incidents had led to improvements, according to staff and leaders.

Staff we spoke with reported that they had received feedback from incidents and that feedback was shared. The service’s compliance with duty of candour requirements was 100%. This meant the service was open and honest when something went wrong, they told the person or their family what had happened, apologised, investigated the issue, and shared what they did to prevent it happening again.

The service did not always work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Staff did not always make sure there was continuity of care, including when people moved between different departments. Despite the presence of a formal transfer policy, the absence of a structured and consistently applied handover process resulted in omissions that compromised continuity of care.

We observed examples of patients being handed over to other services without critical information being included such as time critical medications, patient communication needs and relevant medical history, which could lead to delays in treatment.

We also observed a patient, being treated for cancer, who had been transferred from UEC to Same Day Emergency Care (SDEC). Due to a poor-quality handover, staff in SDEC were not made aware that the patient was receiving cancer treatment and had a weakened immune system. As a result, the patient, waited further in a crowded area without staff recognising the heightened risks associated with their treatment and vulnerability. The patient was visibly distressed while waiting in an inappropriate environment for their clinical needs. This was escalated to staff at the time. Trust leaders have since implemented a management of acute oncology patients attending the UEC standard operating procedure.

We saw at times there were prolonged delays in ambulance handovers, resulting in patients remaining on trolleys for extended periods before being handed over to hospital staff. We identified a safety concern where the department relied on a national initiative that would free up ambulance crews and enable them to respond to emergency calls. This allowed ambulance crews to leave patients after 45 minutes without completing a formal handover to hospital staff. However, whilst there was a process in place for these patients, this was not always followed, particularly during busy times.

We observed a departmental medical handover which was not well structured or timely. This was addressed by leaders following inspection feedback, who developed a document based on Royal College of Emergency Medicine guidance that provided a structure for staff to follow.

At our follow up inspection, we saw that this new document had been introduced which included specific areas to ensure all pertinent information was covered. We observed that the document was in use and staff reported that handovers were more effective and efficient.

We saw that there were pathways in place to stream patients out of the main department and that there were set exclusion criteria, but staff gave us examples of patients who had been inappropriately streamed.

We saw that high‑risk patients were left in waiting areas without appropriate clinical observations. We saw an example of a patient with a significant head injury in the waiting room who had not received monitoring, as determined by trust policy.

Some staff reported that systems for placing alerts on patient records were not clearly defined, and there was uncertainty regarding who was responsible for adding and maintaining these alerts. People who attended four or more times per month, were not reliably flagged in the IT system, which created inconsistencies in risk identification.

We noted the emergency department staff provided nursing care for those patients awaiting review from different teams within the hospital. This caused increased demand on the staff and space available for patients.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always share concerns quickly and appropriately. It was not ensured that all staff completed the required training.

We found that only 65% of medical staff had completed both the adult and children’s safeguarding training modules, which was below the trust’s compliance target of 90%. Nursing staff met the required level for adult safeguarding training; however, compliance for children’s safeguarding was lower, at 89%, and did not meet the trust’s target.

Trust compliance with the mandatory training requirement in learning disability and autism was poor. Whilst over 90% of staff had completed eLearning, there were no areas of the division where compliance with the training requirement was above 20%. This meant there was a risk that staff were not equipped with the necessary skills to meet the specific needs of patients with a learning disability or those who were autistic. We saw evidence that staff were not considering reasonable adjustments routinely, able to consider the communication needs or the impact of restrictive practices on patients with a learning disability or those who were autistic. The trust had a plan for increasing compliance in the coming year; however, we could not be assured that staff were trained and able to meet the specific needs of vulnerable patients. This was a breach of Regulation 18.

Safeguarding processes were not always working effectively. Staff often waited until after an incident to check on people or record what had happened. This meant people were not protected when they needed it, and this increased the risk of avoidable harm.

We witnessed two vulnerable patients being returned to their supported living accommodation in a shared taxi. This caused one of the patients to look visibly upset by the arrangement, there was no consideration of individual preferences or emotional comfort.

We witnessed another case, where a vulnerable patient presented with an overdose. There was no evidence in the clinical record that a formal safeguarding concern was raised by any of the professionals that saw the patient. There was also no record that staff discussed a safeguarding referral with this patient.

We saw an example of a vulnerable patient, who attended the UEC on multiple occasions in a 5-month period. Whilst a safeguarding referral was made following their first attendance, there were no other referrals made despite clear vulnerabilities and risks which were evident. The trust did not have assurance that staff took opportunities to safeguard patients living in vulnerable circumstances.

We observed a vulnerable patient, who had presented to UEC with a head injury, and was taking blood thinners, reported they were frustrated with waiting and left without being seen. No welfare checks were undertaken until prompted by the inspection team. There was no completed self-discharge form and no record of attempts to contact the patient.

Clinical staff told us they received basic training on mental capacity as part of their mandatory mental health training. However, they reported that this training did not provide in‑depth knowledge of the Mental Capacity Act (MCA) or the legal framework.

Nurses and healthcare staff we spoke with said they did not feel confident in assessing capacity, and many were unable to articulate the principles of the mental capacity act, including how capacity is determined or how best‑interest decisions should be made. Staff were also unable to describe the legal implications of failing to assess capacity appropriately, either for patients or for themselves as practitioners. This meant there was a risk that patients were not involved in decisions about their care and treatment in a way which was meaningful, impactful or effective.

We identified a gap in safeguarding documentation within a paediatric record. The consultant review was recorded retrospectively, and safeguarding rationale was not documented beyond screening. There was no record of how concerns were excluded or whether the mechanism of injury was developmentally appropriate. This reduced assurance that safeguarding risks were fully considered or acted upon promptly.

The electronic triage system required staff to complete mandatory safeguarding questions before progressing. All children under one year prompted a Bumps, Burns and Scalds (BBS) assessment, which staff understood well and used consistently.

Staff completed paediatric liaison forms when they had ongoing concerns. These were reviewed by the safeguarding team, who made referrals to external agencies when needed. Staff described the process as responsive and supportive, helping them act proactively.

There was a strong culture of open communication and shared safeguarding responsibility. Staff said there were no hierarchical barriers to raising concerns, and doctors were approachable. Safeguarding was viewed as a whole‑team duty.

The Mental Health Liaison (RAID) service provided specialist assessment and support to patients attending the ED who were experiencing mental health difficulties or an acute mental health crisis. The service operated 24/7 at the trust.

The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Although a range of risk assessments were available electronically, not all risks were assessed in a person‑centred way. Staff could not confirm whether a bed rails risk assessment existed, and during the inspection we saw almost all patients had bed rails raised with no documented justification. This meant people were not given the opportunity to discuss the risks and benefits, limiting their ability to make choices about their safety. Improper use of bed rails placed some patients at an increased risk of harm.

Staff attempted to communicate with people, but interpretation services were not consistently used. Instead, staff relied on family members for communication support. This meant there was a risk that important information was not accurately understood, leading to miscommunication about symptoms, care needs or consent, and reducing the patient’s ability to participate safely and effectively in their care.

The trust used the National Early Warning Score (NEWS 2) to assess patients at risk of deterioration in the department and enable staff to take appropriate action. In the paediatric department this was the Paediatric Early Warning Score (PEWS). Staff were clear how to escalate patients that needed clinical review. The service had an escalation policy for the deteriorating patient. However, we found medical staff compliance with NEWS2 training was only 52%.

Staff knew about and dealt with any specific risk issues such as possible sepsis, and there was an in-date policy for the early recognition and management of sepsis. There is national guidance for how quickly patients should receive treatment for sepsis based on their presentation. Following review of sepsis audits, we saw that between February and December 2025, the department achieved an average of 84% compliance for sepsis management of high-risk patients and an average of 91% for moderate risk patients, which are both above the trust target of 80%.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Reception staff had a good overview of the main waiting area and were able to describe the process for responding to a deteriorating patient. However, we observed that clinicians had limited visibility of waiting areas. This meant patients in these areas were at increased risk because staff could not easily observe changes in their condition, identify deterioration promptly, or ensure timely escalation of concerns.

We observed inappropriate placement of vulnerable patients in the waiting room, often waiting for prolonged periods of time with no oversight of the waiting room or clinical staff checks.

These concerns were shared with leaders who, in response, drafted a standard operating procedure for the management of patients in the waiting room. It described key principles for suitability, criteria and assessment and management of risk.

Some clinical staff told us that paediatric and neonatal emergency resuscitation equipment was not easily accessible and stored in various locations. This meant there was a risk that essential equipment would not be immediately available in an emergency, causing delays in life‑saving interventions and reducing the team’s ability to respond safely and effectively.

Whilst signage within the UEC environment was easy to follow, we found that directions to the SDEC were not easy to follow, signage was confusing and contradictory. However, we observed staff offering advice to patients and asking if they needed help or directions.

Staff reported periods where the department felt unsafe due to high demand and patient acuity, particularly at night, with paediatrics a particular concern. They continued to prioritise safety and manage risks as effectively as possible.

When we visited the department in the evening, we saw that the department was experiencing significant overcrowding, with 83 patients present in the unit against an environment already operating at 100% occupancy. Patient flow was severely constrained, resulting in extended waits and patients being accommodated in unsuitable areas.

Corridor care compromised patients’ safety, privacy and dignity, and limited staff’s ability to provide safe care. Patients, including those with cognitive impairment, were cared for in corridors which limited staff oversight. This was a breach of Regulation 10. However, on the night of the inspection the organisation was operating at high Opel 3. This meant there was high pressure on the department due to how busy it was. The surge and escalation plan had been enacted.

We saw examples of the department running out of equipment for patient care, such as bedding due to demand within the department.

Whilst the mental health room was PLAN (psychiatric liaison accreditation network) compliant, bathroom facilities for the designated mental health room were not anti-ligature, this had been identified at the previous inspection but had still not been addressed. The facilities also contained several risks, including a potentially hazardous cleaning substance. This was a repeated breach of Regulation 12.

The department did not have a dedicated children’s mental health room. However, there was a designated room that could be utilised for children requiring mental health assessments. We did note this room was not PLAN compliant.

Staff followed safe procedures for children visiting the department. Access to the paediatric waiting room was via a door buzzer system and staff carried electronic passes to gain entry. A tailgating poster was displayed to reinforce secure access protocols and remind staff to maintain controlled entry.

In the paediatric corridor, we observed a range of toys and play equipment available for children. These were cleaned each night. Water and juice were available for patients waiting in this area.

The paediatric area had a dedicated X‑ray room, and the radiographer attended the department when required. This meant children did not need to leave the corridor for imaging, helping to minimise movement and maintain a child‑friendly environment.

During the inspection we conducted environmental checks, and the department was clean, tidy and well maintained. The department was spacious, free from clutter, and did not contain items that could create trip or falls risks for patients, visitors or staff.

Equipment reviewed during the inspection was well maintained, PAT tested, and clean. The major incident store and associated equipment was fully checked in date and maintained, with items stored in an orderly and accessible manner.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

We reviewed the staffing rota which showed the paediatric department was not always staffed in line with best practice or as recommended by the Royal College of Paediatrics and Child Health (RCPCH). We raised this during the inspection and the trust provided evidence of measures in place to manage departmental staffing risk.

Rota data from the 6 months preceding inspection showed recommended paediatric staffing levels were not consistently achieved in line with national guidance. The department had only one registered nurse on 28.7% of day shifts and 25.9% of night shifts. To mitigate this, the trust used adult nurses who completed a locally developed five-day paediatric course aligned to Royal College of Nursing Level 2 competencies. Compliance was 78%.

We found that the service did not always have a dedicated paediatric doctor available. This meant that on several occasions children were required to wait in the same queue as adults to be seen by the clinician on duty, in priority order. This meant children could experience delays in assessment and treatment, with a risk that their specific clinical needs were not identified or prioritised promptly.

The trust did not have a Paediatric Emergency Medicine (PEM) consultant onsite. They worked cross site and travelled across when needed. However, 100% of consultants were advanced paediatric life support trained.

Patients told us that the department ‘seemed understaffed at times’ but they felt staff were doing the best they could, one patient told us the staff looked stressed and one had their “head in hands” at one time.

We found that there was not always a streaming nurse on duty due to short staffing. Staff were, however, able to describe the standard streaming procedure and outline what should normally occur when staffing levels were adequate.

Leaders told us that for nurse staffing, agency usage had reduced and mostly consisted of bank staff familiar with the department. Data showed that from October 2025 to December 2025, 17% of shifts were filled by registered bank and agency staff. Leaders told us that most bank staff were substantive at the trust in their areas.

Managers calculated and reviewed the number and grade of staff needed for each shift according to best practice and department need.

There was a structured development programme for all staff that included unit and role specific induction programmes and supernumerary periods for new nurses to the team.

Managers supported staff to progress through regular development meetings and yearly constructive appraisals of their work. Staff had the opportunity to discuss training needs and were supported to develop their skills and knowledge. Staff were supported by their managers and the practice educator to improve their practice where indicated.

There were several role specific training modules where compliance was below the 90% trust compliance rate, including end of life care level 2 (87%) and nasogastric tube insertion and management (70%). Low training compliance puts patients at increased risk as staff may not have the skills and competencies to respond to emergency situations. This was a breach of Regulation 18.

Whilst the team had access to a clinical educator, they did raise concerns that there was no clinical educator with a paediatric background, increasing the risk that education did not fully meet the specific needs of those caring for children.

The service had 4% vacancies for both registered nurses and medical staff.

The average sickness absence rate for nursing staff was 5% and 2% for medical staff, both of which were below the national average of NHS sickness absence rate of 6% (October 2025).

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

We observed unsafe practice in relation to infection prevention and control and food hygiene and safety. Staff had provided a patient with breakfast, which had been placed on a metal phlebotomy trolley next to opened blood cultures and a needle left exposed. This presented a clear contamination and sharps risk and did not follow safe national infection prevention and control (IPC) or health and safety guidance.

We reviewed the infection prevention quality improvement audit from October 2025; this had an overall score of 84%. The lowest three areas were cleaning of general corridors and thoroughfares (50%), patient equipment (63%) and the clean and dirty utility (67%). We saw evidence of a range of other IPC related audits, including sharps safety and personal protective equipment (PPE) the compliance for these ranged from 89%- 100%.

We reviewed hand hygiene audits, which showed an average compliance rate of 99% between January and December 2025. However, we observed poor hand hygiene and adherence to policies during the inspection. We observed several staff members wearing inappropriate jewellery and nail varnish, which does not comply with guidance and presents a potential infection risk. This was a breach of regulation 12.

The department was visibly clean, and we saw that cleaning schedules were completed and up to date. Cleaning charts demonstrated when domestic tasks had been undertaken, and disposable curtains were in use with change dates correctly recorded and in line with required timeframes.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Medicines were stored safely, securely and were well organised with temperature monitoring completed to ensure medicines were safe to use in most of the areas visited during the inspection. The medicines room in UEC SDEC did not have temperature monitoring taking place. Temperature monitoring of this area was introduced by the Trust following inspection. Controlled drugs were stored securely with restricted access, accurate record keeping and there was a process in place to report any discrepancies.

Stock was not always managed well; we found that some medicines stored in fridges were out of date. These had not been identified by staff or the medicines management and administration audit and posed a risk of expired, ineffective or unsafe medicines being used.

Of the 7 patient’s records we looked at, 3 did not have a comprehensive medicines history recorded therefore patient’s required medicines were not always prescribed in a timely manner. A medicines reconciliation service (comparing the list of medicines people were taking prior to admission with what was currently prescribed) was not provided within the UEC department. This put patients at risk of not receiving the correct medicines. There were no designated pharmacist or pharmacy technicians to support the UEC department. This was not in line with the current guidance recommendations set out by the Royal College of Emergency Medicine.

Where antibiotics had been prescribed, there was not always a clinical reason documented or the length of treatment.

Where patients were identified as having a high risk of sepsis, there were variations in how quickly medicines were administered, with one patient having treatment initiated within 1 hour of identification and another patient received their medicine nearly 3 hours after it was prescribed. The records we reviewed did not include clear reasons for delays to medicines administration.

The trust had previously recognised that improvements were needed in this area to improve timeliness of antibiotic administration aligned to the sepsis pathway. They had implemented a patient group direction (PGD) to allow staff to provide timely administration of antibiotics, including using ready to use sepsis antibiotics to reduce administration delays.

The medicines management training information provided by the trust showed that compliance was 92% for emergency nurse practitioners, 91% for UEC nursing, 81% for UEC medical staff and 68% for UEC resus team. The trust recognised further progress was required to ensure the appropriate target audience was assigned to the training to ensure all staff were trained in medicine management.

Details of patient allergies were documented well in all patient records reviewed. PGDs were available, signed by the relevant people and in date for staff to use when certain medicines were required.