Huddersfield Royal Infirmary

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• 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

This means we looked for evidence people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

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. Managers listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

OPD (outpatient department) staff had a good reporting culture where they felt safe and encouraged to report incidents, concerns, near misses, and feedback. All staff knew what incidents to report and how to report them.

Staff raised concerns and reported incidents and near misses in line with the service’s policy.

The division had one never event in the 12 months before our assessment. This was a documentation error which caused no harm in July 2025. This divisional data could not be broken down to location specific information. We saw that it had been managed in line with trust policy which included compliance with their professional responsibilities under duty of candour.

The service could evidence changes made after feedback. Learning responses for any patient safety event were tailored to each case, with person‑centred care at the core of continuous improvement. All areas displayed dashboard information about the last serious incident date. In many cases this was more than 12 months before our assessment.

OPD leads undertook thematic reviews where incidents presented safety risks. The trust identified a series of near‑miss incidents in outpatient and virtual clinic settings. These highlighted a recurring safety risk. This led to the right patient, right clinic right time initiative. This reinforced staff’s need to ensure checking the right patient, in the right clinic, at the right time remained a fundamental patient safety process. The trust created and shared a related learning resource in response. They also displayed posters focused on critical pre‑consultation checks. This meant staff safeguards were built into standard operating procedures for outpatient and virtual clinics.

During our assessment all OPD clinic areas had 222 incidents open, under review or pending. However, of these only six were graded as moderate harm and two as severe harm. This divisional data could not be broken down to location specific information.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service worked to improve pathways and continuity of care for outpatients through joined-up clinics. There were safe and standardised referral pathways into the department, as per the trust’s elective care access policy.

Staff adhered to the trust’s right patient, right clinic, right time initiative. This ensured before any OPD consultations began, staff checked all outpatients’ full name, date of birth and address.

Patient notes were comprehensive, and all OPD staff could access them easily. Staff used a well embedded electronic patient records (EPR) system. Nursing and clinical staff told us the system was accessible and user friendly across all sites. They emailed patients on the system to clarify any missed appointments.

Records were stored securely. The hospital had a back-up system to ensure patient records’ security.

Outpatient staff completed contemporaneous record keeping after the patient’s clinical consultation. They recorded all salient points of the patient’s consultation within the electronic record. This was either done directly, through dictated digital letters, or typed within the EPR system. Leads audited a sample of nursing staff’s record keeping in EPR within the Outpatient front-line ownerships. These encouraged frontline nursing staff to maintain higher standards of documentation.

The service completed record keeping audits of pre-operative assessment medical records. We reviewed an MS Teams snapshot audit from February 2026 which asked seven questions. Analysis showed the five records reviewed for patients with a red flag did not require reasonable adjustments. In most cases, outpatient’s clinical record evidenced clear communication from staff relating to next steps. They maintained record keeping standards. The outpatient services matron was building a regular record audit into the quality assurance programme. This would be fed back through the directorate performance review meetings in future and inform improvement work.

Outpatient admission, inclusion, and exclusion criteria were clearly defined in alignment with the hospital’s latest statement of purpose and the NHS e-Referral Service (eRS) Directory of Services.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

OPD staff received and kept up to date with training specific for their role on how to recognise and report abuse. Staff were appropriately trained in line with the intercollegiate document. During our assessment safeguarding training compliance for outpatient nursing staff was 100%. This divisional data could not be broken down to location specific information. This included the provision of safeguarding supervision. In addition to the role specific requirements, supervision was provided to support individuals on a case-to-case basis. The trust could not breakdown the latest safeguarding training compliance for medical staff. This compliance sat within specialties, as none were line managed within the OPD directorate.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. They followed processes supported by several trust policies to guide them. Staff had easy access to key information, documents, and referral processes on their intranet to implement policies.

Booking and administrative staff would establish parental responsibility for any children upon their arrival in the department. Any ‘looked after children’ were flagged or checked on their EPR system. Staff followed a ‘was not brought’ policy for children or vulnerable adult outpatients. They would contact the safeguarding team for patients who did not attend (DNA) regularly.

Paediatric and specialist surgical staff told us about treating several cases of female genital mutilation (FGM) and taking appropriate safeguarding actions. Staff covered FGM guidelines as part of their safeguarding training.

Safeguarding policies applied for paediatric and vulnerable people in OPD areas. Staff considered outpatient’s non-attendance in a risk-aware context and would follow up and flag to try and contact all DNAs.

Staff knew what action needed to be taken when someone went missing or were at risk of going missing as per the trust’s missing person policy. The policy had flowcharts staff followed, and referenced the Herbert Protocol (A UK initiative that helps carers record key details—like routines, usual places, and a recent photo—so police can quickly act if a vulnerable person goes missing).

OPD staff followed relevant provider and hospital adult safeguarding and chaperone policies. Chaperone information was displayed throughout OPD areas. Most patients we asked knew they could request this if needed.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff responded promptly to any sudden deterioration in a patient’s health during OPD clinic opening hours. All staff we asked knew the procedure if someone collapsed or suffered a cardiac arrest

However, we heard some medical outpatients could arrive early for their appointment, before any staff were in the department. On occasions staff had found patients sat in the second-floor reception with the lights off before 8am upon their arrival. This meant we were unsure how certain clinics mitigated potential risks around safeguarding, fire safety, and medical emergencies.

We heard senior staff’s emergency response expectations could be inconsistent between clinics. For example, children’s services did not need to respond to adult emergencies, and did not carry a crash bleep. However, medical outpatients staff were frequently asked to attend emergencies elsewhere, outside their own department. This left their area understaffed, and increased risks for outpatients left unattended.

The absence of staggered reception cover left some departments unsupported when outpatients had issues other than bookings. Where self-check-in machines were out of order, patients needed a staff member to manually confirm their arrival. This placed increased pressure on clinical staff during periods of reduced cover.

Staff checked resuscitation trolley top drawers daily, completed weekly checks and updated records. All OPD areas had their own resuscitation trolley located near to waiting areas. We reviewed the trolley checklists and contents. No equipment or dates had been missed. Trolleys included child-specific equipment in clinics which saw and treated paediatric patients.

OPD staff knew about and dealt with any specific risk issues. They individually assessed all patients to ensure a safe and appropriate clinical environment.

Nursing and support staff completed appropriate risk assessments for patients.

Shift changes and handovers included all relevant key information to keep patients safe.

All staff understood the department’s eligibility criteria. They would confirm any discrepancies with their managers.

OPD staff routinely updated risk assessments, and reviewed incidents through hospital governance meetings.

The service could not detect and control all potential risks in the care environment. Leads could not always ensure equipment, facilities and technology supported the delivery of safe care.

Patients and carers we asked could not always easily find their clinic location. Not all visiting and first-time patients could park or knew where to arrive.

The division had many environmental and digital issues across clinics. For example, phlebotomy staff could not easily lower their adjustable chairs if patients fainted after their bloods were taken. We saw three broken self-check-in screens in main OPD reception for bloods, general and medical outpatient areas. Not all broken screens had signs informing new arrivals where to go, who to inform they had arrived and when they could be seen. This meant some outpatients left the department or had to remind staff before being seen.

The Acre Mills site separate to the main hospital OPD services had no onsite security. This meant if incidents or threats occurred, staff were expected to contact the main hospital for support. This delayed security response times and left some staff and patients feeling unsafe.

We also found equipment-related issues in women’s health. Equipment safety testing was found to be out of date and staff were unsure when servicing would be carried out. Medical outpatient staff told us restricted items could take at least a few months to replace, such as adjustable beds. This meant we could not ensure environments and equipment were appropriate, available or safe for use on outpatients, potentially putting them at risk. This was a breach of regulation 15(1)(c) around premises and equipment.

Trust leads took prompt action to address these equipment issues. All out of date equipment was removed and broken equipment reported for repair or removal.

OPD had an ongoing procurement process to replace the check-in screens. Leads would follow this up to establish a timeline to implement new screens.

We found and staff relayed a lack of toilet facilities in or near the gynaecology department and surgical outpatients. Gynaecology outpatients ligature risk assessments had not been reviewed since 2022.

Surgical outpatient’s waiting area was still very small and limited to a few chairs. Staff and signs said they prioritised these for transport patients or those with complex needs. We raised this small waiting area concern on our last service inspection in March 2016.

Some clinics and pharmacy areas lacked storage space. For example, the drop-in blood clinic had to store consumables on window ledges. Surgical outpatients and the women’s gynaecology unit lacked ventilation to ensure air supply when using medical gases such as Entonox or penthrox. We were unsure if risk assessments or environmental monitoring were in place to mitigate these risks.

Surgical outpatients had to wait for their appointments along an external communal corridor and in some cases complete forms with personal sensitive information.This meant privacy and confidentiality was lacking for these patients. Mortuary and patient trolleys could pass by which potentially caused people distress and a poorer experience.

However, the design of the environment followed national guidance. We saw signage and directions to outpatient department clinics and areas was easy to follow.

Some environments were designed to meet the needs of their service users. For example, the children’s outpatient’s department had a fish tank, colourful wall murals and play facilities for children waiting. The Rainbow centre community hub delivered clinics for special educational needs and disabilities (SEND) and neurodisabled children, young people and their families.This was a purpose-built facility specifically designed to meet complex developmental and sensory needs. However, few of the waiting areas were dementia‑friendly or had facilities for children.

Staff ensured the department was a safe environment by controlling some potential risks. They checked and challenged unfamiliar visitors. Registered nursing staff checked all rooms were decontaminated and logged digitally at the end of clinic lists. Laser safety lights above clinic doors were used and turned on during procedures. The laser key was held in a secure location known to staff. All laser records were held electronically. The division had a laser protection supervisor. We reviewed the trust’s closed-circuit television (CCTV) and use of body worn cameras policy. Staff told us this had reduced incidents of violence, aggression, verbal abuse, antisocial behaviour and malicious complaints within OPD.

Staff carried out safety checks of specialist OPD equipment. Medical devices were calibrated at the point of service. Most diagnostic equipment was maintained through contracts with external companies. We saw some equipment maintenance in ophthalmology during our assessment.

Managers could request additional resources to ensure or promote the quality of care and treatment. The service had enough suitable equipment to help staff safely care for patients.

Staff followed fire safety precautions to ensure they worked in a safe environment. Staff completed weekly checks of all fire-related equipment.

We saw evacuation signs and procedures were clearly marked throughout the department and clinic areas. All staff undertook e-learning and face to face fire safety training. Fire safety training was included in their site induction and refreshed yearly. Fire drills were completed at least biannually to ensure compliance with fire safety processes.

All clinic floors and areas had assigned fire wardens and representatives onsite during opening hours. Staff we asked knew fire procedures and how to direct patients and other visitors to safely exit the premises.

Staff disposed of clinical waste safely. Sharps containers were signed, dated and not filled above the line. One sharps bin in surgical outpatients was not fixed to the wall and open at child height. This meant it was not safely stored and could be a potential hazard.

The trust had an in-date policy for prevention and management of clinical sharps injuries and exposure to blood and high-risk body fluids.

The service ensured there were enough skilled, experienced and qualified nursing staff. They received effective support, supervision, training and development. They worked together well to provide safe care that met people’s individual needs.

The service had enough nursing and support staff to keep outpatients safe. OPD staff sickness rates from February 2025 to January 2026 averaged 7%. This did not meet the trust target of 4.3%. Trust leads told us due to the small number of colleagues in some OPD teams, the sickness rate could seem higher. The department’s aging workforce and long-term conditions impacted their sickness rate. Leads had mitigations in place to manage operational gaps by cross-site working, bank staff use and part-time staff. This meant the number of cross-site nurses and CSWs matched those planned.

Managers adjusted staffing daily based on patient need, with Band 6 staff completing weekly rosters. Staffing tools supported oversight of safe levels. Most staff worked cross‑site, and each clinic had a designated lead

Staff completed essential safely training (EST) e-learning annually. Staff we asked had completed all their yearly EST including refreshers. Most modules were e-learning online.

During our assessment overall outpatients EST compliance was 94.5%. Gynaecology team training compliance was 92%. Both these figures narrowly missed the trust compliance target of 95%.

Staff told us their EST was comprehensive and met the needs of patients and staff.

Staff received and completed training specific to their role, including bank staff. For example, surgical outpatient staff were trained to apply vascular dressings. Ophthalmic staff had a bespoke training package which included intravitreal injection therapy.

Line managers monitored all outpatient teams’ essential skills training compliance. They alerted staff when they needed to update their training. It was staff’s responsibility to complete all essential safety and role-specific training. Staff’s training compliance was a focus in performance review meetings. This supported oversight and ensured any gaps were addressed promptly. In order to progress their pay, staff had to have an appraisal as per the trust’s pay progression policy.

Ophthalmology had trained two staff members to provide in-house basic life support (BLS) training to colleagues. This addressed essential safety training non-compliance and ensured their service met trust target.

Managers gave all new staff a full induction tailored to their role before they started working in the department. OPD leads gave all new starters a corporate induction booklet. Nursing and healthcare assistant staff also attended a local induction session. This gave them essential information about departmental procedures, key contacts, and department-specific expectations.

The service had a low vacancy and turnover rate. Staff vacancy rates across all Outpatients services for the 12 months from February 2025 to January 2026 averaged at 7%. This did not meet the trust target of 4.3%. However, this rate had improved during the annual period. Some areas with primarily administration roles had above average vacancy rates. The most common cause of staff leaving was retirement. OPD leads had mitigations in place to manage operational gaps by cross site working, bank staff and part-time staff use.

Nursing leads could access a fully trained and embedded trust bank team. For example, the paediatric clinic manager regularly used bank staff who were offered regular shifts. They knew the consultants in clinic well and had gained good working relations.

OPDs could include any additional, role-specific competency requirements within their bank staffing adverts. Divisional ADNs approved and aligned required competencies for bank staff for all essential and role-specific training required. Leads gave all bank-only staff a three-month window to ensure their competency was in line with the approved competencies.

Managers supported all staff to develop through yearly appraisals of their work. They supported staff’s learning and development needs. These were completed in April 2025, and the gynaecology team had completed 100%. Eye clinic appraisal compliance was 94%. Managers reviewed staff on probation at their next appraisal or one to one.

However, despite the low overall vacancy rate, nursing leads could not always access extra nursing and support staff. Several clinics had ongoing or longer-term band 6 and 7 nursing staff shortages. This was often due to seasonal or longer-term sickness and maternity leave.

Not all reception areas had a staff member present, some of these had self check-in machines instead. Some check-in machines had signs asking patients to use other clinic reception desks. Staff said they supported patients who struggled using the machines. Charge nurses hot-desked behind reception to cover receptionist sickness and lunch breaks.

One matron told us their staff’s multiple flexible working arrangements made their rostering a challenge. Some office staff told us their cross-site working meant they had less continuity and knowledge about clinics. One staff member was unsure where resuscitation equipment was located.

Some nursing staff told us their training opportunities, upskilling and leadership development was limited due to workload pressures or having no spare staff to cover their shifts. We heard a clinical staff member could not progress with their job description responsibilities. We heard staff’s time and support to complete essential safety training and revalidation at home had reduced in the last few years since the Covid-19 pandemic. Nurse consultants were concerned about the lack of succession planning within their breast team.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Some audits showed non-compliance in outpatient department.

Infection prevention and control (IPC) data showed most areas achieved 100% in hand hygiene and OPD environmental audit compliance. All areas gained a 5-star cleaning score.

OPDs undertook a range of audits to provide assurance around IPC practices and environmental cleanliness. The department had achieved 100% compliance for the past three months. For example, in paediatric outpatients the hand hygiene monthly assurance reports from January to December 2025 was 100%.

Staff carried out additional audits and spot checks during infection outbreaks. Oversight of any issues was through the trust’s IPC strategic meeting with divisional reporting into the Patient Safety Quality Board (PSQB).

Nursing teams carried out biweekly front-line ownership (FLO) audits. The FLO audit’s IPC elements included antiseptic non-touch technique (ANTT), correct use of PPE, uniform policy and assurances around safety, cleanliness and compliance of the general environment.

All OPD areas consistently achieved a five‑star cleaning rating in line with NHS audit standards. Hand hygiene and FLO audit results were routinely discussed and shared during safety huddles. FLO audit data reviewed for November 2025 to January 2026 showed overall compliance of 90% or above across most areas; however, two OPD areas fell below this standard in January 2026. These were HRI Lower Ground (Sexual Health) at 80.5% and HRI Lower Ground (Orthopaedic) at 86.6%, with several Sexual Health metrics scoring as low as 50%.

The orthopaedic area showed a downward trend, decreasing from 89% in November to 86.6% in January, including particularly low scores in December for maintenance and storage standards. We saw no evidence that actions had been taken to address these areas of non‑compliance.

OPD had an infection prevention quality improvement audit action plan from September 2025 which fed into the matron’s report. All actions were completed except for four ongoing. Two of these related to storeroom and dirty utility cleaning checklists, as these still needed printing. We found storage shortages leading to a lack of cleaning in some areas during our onsite assessment.

We reviewed all the trust’s IPC policies relevant to OPD practice. Staff could access a suite of infection prevention and control policies available on the trust intranet. Staff could access extra advice from the IPC service as required. The department used the National Infection Prevention Control Manual.

The trust had policies in place to prevent and manage infectious diseases such as

Methicillin-resistant Staphylococcus aureus (MRSA). OPD had reported no infections in the last 12 months.

Cleaning records were up to date. We found no gaps or errors in OPD deep clean records. Staff cleaned all areas including toilets daily. There were signs promoting correct handwashing techniques. Hand sanitiser dispensers were in appropriate areas by the entrance to most clinics.

Staff followed infection control principles including the use of protective personal equipment (PPE). We observed OPD nurses and support staff using suitable PPE for patient treatments. For example, during blood tests they wore a mask, apron and sterile gloves. Post-treatment they turned the gloves inside out into the peddle-bin.

Staff cleaned furnishings and any equipment after patient contact. All decontamination of any devices used in OPD was completed onsite.

We saw cleaning materials and documents met control of substances hazardous to human health (COSHH) regulations. These UK regulations are designed to protect workers from health risks associated with hazardous substances. They were stored safely and securely in a locked cupboard.

The service ensured medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen. However, staff did not always store or manage prescribing documents safely.

Staff followed systems and processes to prescribe and administer medicines safely. We saw nursing staff checked patient’s identification and allergy status before proceeding. Outpatient staff completed prescribing using the electronic patient record (EPR). This software had functionality to flag allergies and alert prescribers if they try to prescribe medicines to which the patient was allergic. Any interactions between concurrently prescribed new medications in OPD settings were immediately flagged for clinician review.

Staff completed training on how to use the trust’s electronic prescribing and medication administration as part of their induction. The trust made system prescribing training mandatory in 2025 for all new resident doctors. They had allocated time to complete this training. All non-medical prescribers received e-prescribe training before they were allowed access to system prescribing. OPD pharmacy staff were trained in documenting medicines reconciliation and interventions on the electronic patient records (EPR) system as part of their induction.

Staff reviewed each patient’s medicines regularly and could access a lead pharmacist onsite.

Pharmacy technicians completed ambient temperature room and fridge checks for medicines throughout the department. Where fridge temperature deviations were outside of normal range, the clinic team were automatically alerted. The on-call pharmacist received alerts if the Acre Mill eye clinic fridge went out of range outside working hours. They moved stock if there was any sustained temperature deviation.

Staff completed medicine records accurately and kept them up to date. They checked patients had the correct medicines early in their pathway, and when they moved between services. Staff provided advice to patients and carers about their medicines. We checked six outpatient’s medical records which were completed appropriately.

OPD areas undertook medicines audits for assurance of safe management and storage. We reviewed the latest medicines management annual peer audits in medical outpatients and ENT from September 2025. All areas for medical OPD were compliant, with no identified improvements. The ENT audit advised one action to improve oxygen signage.

OPD followed trust policies related to medicines. Staff could access these on their intranet. The nurse in charge was responsible for medicines storage compliance. All medicines were stored within designated medicine cupboards. These were behind closed, digi-locked coded doors. Medicine cupboard keys were held separately in locked coded boxes in a separate location. Regular leadership walkarounds entailed checking medicines storage and ensuring digi-locked doors were closed.

Staff stored and managed all medicines safely. We checked ten medications in the surgical outpatient store. All were in date and stored appropriately. Nursing staff were responsible for monthly stock orders and regular rotation, with help from pharmacy staff.

Staff across all OPD areas had completed medicines management training. Five bespoke role-specific training (RST) medicines modules included preparation, administration, storage and security. OPD managers and matrons reviewed RST compliance. This was also reviewed at directorate boards and divisional Performance Review Meetings (PRMs) as part of normal essential safety training reviews.

Staff learned from medicine-related errors and complaints. For example, leads received a complaint around the prescription renewal process for the nurse‑led gynaecology clinic to administer injections which managed conditions. In response consultants implemented several improvements and process updates. This strengthened communication, prescribing safety, and governance oversight.

Staff learned from medicine-related national patient safety alerts and incidents to improve practice. We reviewed four recent medication related incidents in the department from November 2025 to January 2026. Two of these occurred in trauma and orthopaedics. All had different categories and resulted in no harm.

Consultants could ask the pharmacist onsite to provide FP10 outpatient prescriptions. These were specific forms used by healthcare professionals to prescribe medications to patients in primary care. OPD clinics stored no controlled drugs onsite. Prescribing staff used FP10s as needed when the pharmacy was closed. These were kept locked in a secure location.

However, staff did not always store or manage prescribing documents safely. 3 of the 6 FP10 forms we reviewed were missing or had incomplete documentation. All were between July and December 2024. Prescribing staff in the surgical outpatients’ service had three pads simultaneously in use. This meant we could not ensure staff recorded, monitored or audited these prescriptions consistently.