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Calderdale Royal Hospital Good

Inspection Summary

Overall summary & rating


Updated 20 June 2018

Our overall rating of the hospital improved since the last inspection. We rated it as good because:

  • We rated the hospital as good overall. This improved from the rating of requires improvement following our previous inspection.
  • We rated caring at this hospital as good. This stayed the same as our previous rating. Across all the services we inspected, we found staff treated patients with kindness, compassion, and respect. Patients and their relatives commented positively about the care they received.
  • We rated effective, responsive and well-led at this hospital as good. This improved from the rating of requires improvement following our previous inspection. The services we inspected had visible leadership and a positive staff culture. There were effective systems in place for governance, risk management and quality monitoring. Services were planned and delivered to meet patient needs and most patients were admitted and discharged from the hospital in a timely manner.
  • Our rating for safe at this hospital stayed the same as our previous rating. We rated safe at this hospital as requires improvement. This was because we rated safe as requirement in the urgent and emergency care and critical care services during this inspection. There was also one service (medical care) that was not inspected on this visit that was rated as requires improvement.
  • We rated urgent an emergency care as good overall. Our rating stayed the same since the last inspection. We rated effective, caring, responsive and well led as good. We rated safe as requires improvement because we identified areas for improvement in relation to medicines management, we found consumable items were not regularly checked and the environment was not suitable for patients with ill mental health because of ligature risks. The service did not meet national guidelines for consultant presence for 16 hours per day.
  • We rated critical care as good overall. Our rating stayed the same since the last inspection. We rated effective, caring, responsive and well-led as good. We rated safe as requires improvement because we identified areas for improvement in relation to consultant cover arrangements, emergency equipment checks and medicines management.
  • We rated the maternity and services for children and young people as good overall. All five domains were rated as good for these services. These had improved since the last inspection. In maternity services, patient engagement had improved since our last inspection and the views and experiences of people who used maternity services were acted upon to shape and improve the service and culture.
Inspection areas


Requires improvement

Updated 20 June 2018



Updated 20 June 2018



Updated 20 June 2018



Updated 20 June 2018



Updated 20 June 2018

Checks on specific services

Medical care (including older people’s care)


Updated 15 August 2016

We rated medical care (including older people’s care) as good overall because:

Staff understood their responsibilities to raise concerns and report incidents. Senior staff managed staffing shortfalls proactively.

Staff delivered evidence based care and overall patient outcomes recorded in local and national audit were good. There was evidence of collaborative and effective multi-disciplinary team working.

Staff cared for their patients. Patients had individual care plans and felt safe. Staff considered physical, emotional and social aspects of wellbeing. Patients were positive about the care received and would recommend the service as a place to receive care.

The division was responding to the internal and external demands placed upon it. Staff made reasonable adjustments in response to individual patient needs and to accommodate vulnerable patient groups.

Managers led the division well with an open and honest culture. Governance arrangements were set up to effectively identify, manage and plan service improvements, efficiencies and to implement actions to mitigate risks affecting upon service provision.


We found the divisional management of patient safety incidents to require improvement, in particular, around incident grading and investigation. The division were consistently below national target for harm free care.

Medicines management needed to improve at ward level to ensure refrigerated medications remain stable and those past their expiry date are disposed of in a timely manner and in accordance with local policy.

There were noted delays in transferring patient care into non-hospital settings compounded by limited integration with community services in the Calderdale area. The division had bed occupancy pressures leading to a number of patients moving after 10pm at night. The division had reported mixed sex breaches.

While staff were passionate about working in the division, a number felt as though there could be better communication from senior management and more attention to their well-being.

Services for children & young people


Updated 20 June 2018

Our rating of this service improved. We rated it as good because:

  • Staff were caring, compassionate and respectful. Staff were positive about working in the service and there was a culture of flexibility and commitment.
  • Feedback from staff, parents, children and young people had resulted in changes to aspects within the service.

  • The service was well led with a clear leadership structure in place. A designated surgeon and anaesthetist was responsible for children’s surgical services.

  • Service monitoring and improvement was managed through governance, performance and risk management systems. Clinical risks were identified with ongoing monitoring in place. The service had identified guidelines and protocols to assess and monitor patient risk and react to changes in risk level. Staff knowledge of the incident reporting process was good and incident-reporting processes were robust.
  • Neonatal staffing met the British Association of Perinatal Medicine (BAPM) guidelines (2011).
  • Resuscitation equipment and neonatal transport systems were regularly monitored. The majority of equipment we saw had maintenance checks confirmed.
  • There was good access and flow within the children’s service. Patients received evidenced based care and treatment and good multi-disciplinary working existed between the children’s services, external providers and the child and adolescent mental health service (CAMHS).
  • The trust mandatory training target was 95%; to-date Mandatory training attendance was 100% in children’s services and 89.7% in neonate services. Arrangements were in place to ensure that the remaining neonatal staff completed their mandatory training by April 2018.
  • During 2017/18, over 96% of staff received an appraisal against a trust target of 100%.
  • Advanced paediatric life support (APLS) trained nurses were rostered on every shift. The trust confirmed that 22 staff had completed the APLS course whilst, 29 staff had completed the neonatal life support course.


  • Aspects of best practice staffing guidance as identified by the Royal College of Nursing (2013) were not fully implemented. However, staffing levels were considered safe by senior management and the staff we spoke with.
  • The service was not compliant against the ‘Facing the Future’ standards because of a lack of permanent consultant cover between 5pm – 10pm. However, the risk had been mitigated as Paediatric Consultant staff were contactable after 5pm.
  • The completion rate for neonatal and paediatric life support training (83%) was below the trust target. Of the 23 staff that had not completed life support training, 16 were booked to complete this training within the next three months.
  • One records trolley on the neonatal unit was unlocked.

Critical care


Updated 20 June 2018

Our rating of this service improved. We rated it as good because:

  • We rated effective, responsive, caring and well led as good and safe as requires improvement.
  • We found there was a focus on training. Mandatory training compliance was high and the number of staff with a post registration certificate in critical care had significant improved.
  • Nurse staffing levels were delivered in line with Guidelines for the Provision of Intensive Care Services 2015 (GPICS) standards and patient outcomes were in line with those of similar units.
  • The systems and processes in place for management of patient records and the assessment of patient risks were reliable and followed national guidance.
  • Care was evidence based and feedback from patient and relatives was positive. The privacy and dignity of patients was maintained and care was compassionate.
  • There was consideration given to the individual needs of patients and there had only been one complaint about the service.
  • Access and flow through the unit had improved. The number of delayed discharges and non-clinical transfers had improved since the last inspection.
  • There was a vision and strategy for the service. There was clear medical and nursing leadership with an understanding of the risks and challenges to the service.


  • There were some areas on non-compliance against the GPICS standards, namely medical out of hour’s provision and dietetic support.
  • There were specific groups of staff with low levels of morale and a lack of designated leadership within the critical care outreach team.

End of life care


Updated 15 August 2016

We rated end of life care services as good overall because:

Patients were provided with an end of life care service that was safe and caring. The mortuary was clean and well maintained.

Staff delivering end of life care understood their responsibilities with regard to reporting incidents and ensured information and lessons learnt were shared proactively with other colleagues within the hospital.

We saw clear, well documented and individualised care of the dying documents and appropriately completed DNACPR forms.

The referral process was clear and responsive and staff ensured that patient’s wishes were central to the care planning process.

Staff had access to specialist advice and support 24 hours a day from a consultant on-call team for end of life care.


The end of Life Strategy / Vision was in draft form. It did not contain business objectives for the team and lacked robust definition of what the vision and outcomes would be for the team in the future.

There was a limited approach to obtaining the views of people who used the service and other stakeholders. There was no mechanism to ensure feedback was captured and actioned in a timely way.

Outpatients and diagnostic imaging


Updated 15 August 2016

We rated the service as good overall. We rated the responsive domain as requires improvement and the safe, caring and well-led domains as good. The effective domain was inspected but not rated. This was because we are currently not confident that we are collecting sufficient evidence to rate effectiveness for outpatients & diagnostic imaging.

Patients, visitors and staff were kept safe as systems were in place to monitor risk. Staff were encouraged to report incidents and we saw evidence of learning being shared with the staff to improve services. There was a robust process in place to report ionising radiation medical exposure (IR(ME)R) incidents and the correct procedures were followed.

The environment we inspected was visibly clean and staff followed robust infection control procedures. Records were stored electronically for X-ray images and OPD had a mixture of electronic and paper records. Staff were aware of their responsibilities within adult and children safeguarding practices and good support was available within the hospital.

Outpatients and radiology nurse staffing levels were appropriate with a low number of vacancies. Radiographer vacancies were higher; a recruitment plan was in place and fifteen staff had been recruited, due to start in the summer of 2016. There were also recruitment issues with ultra-sonographers and breast radiologists. There was an on-going recruitment and retention plan in place.

There was evidence of service planning to meet patient need such as the agreement for purchase of a third MRI scanner. Diagnostic imaging waits were within targets for the national waiting times.

Staff had good access to evidence based protocols and pathways. The OP and radiology departments were very busy during the inspection but patients received good communication and support during their time there. Staff followed consent procedures and had a good understanding of the Mental Capacity Act (2005).

We observed and were told that the staff were caring and involved patients, their carers and family members in decisions about their care. There was good support for patients living with a learning disability or dementia. Staff clearly demonstrated that they put the patient first.

The diagnostic imaging department had a local development plan in place to improve services and the environment. The plan gave a comprehensive review of the demand and capacity on the department to deliver a sustainable and high quality clinical service, taking account of seven-day working plans.

Governance processes were embedded across diagnostics and the pathology and radiology teams felt supported in the new directorate structure however governance processes in OP were less well developed.


People were not always able to access OP services when they needed to. There were issues with appointment backlogs, waiting lists and appointment bookings. Patients experienced long waiting times within the departments, appointment delays and cancellations. Outpatient clinics were often overbooked and we found issues with capacity and demand in all OP clinics. Actions taken to address these issues had not always been effective.

Staff we spoke with were aware of the complaints policy and told us most complaints and concerns were resolved locally.

A high proportion of the total complaints received by

the outpatients

department (22

%) related to appointment problems.

We did not see any evidence to show current trends and themes from incidents and complaints were monitored.



Updated 15 August 2016

We rated surgical services as good because:

The trust had good systems and processes in place to protect patients and maintain safety. Staff understood the process for reporting and investigating incidents and there were good reporting and feedback processes at Calderdale Royal Hospital. Each ward recorded and displayed individual incidences of insignificant, minor and moderate falls, catheterized urinary tract infections (C.UTI’s) and pressure ulcers. Staffing levels and skill mix had been planned and implemented at Calderdale Royal Hospital.

All patients reported their pain management needs were met in a timely manner. Care of patients’ nutrition and hydration were being met as part of the surgical care pathway. We observed care that was coordinated and discharge and transfer planning took account of patient’s individual needs. We observed patients being cared for with dignity, compassion and respect in all the surgical wards and departments we inspected.

Feedback from patients through the NHS Friends and Family Test consistently showed patients would recommend the hospital to friends and family.

The ‘Five Steps to Safer Surgery’ and completion of the World Health Organisation (WHO) checklist was consistently good at the hospital. Mandatory training was well attended and meeting overall training targets was in progress with action plans in place to meet year-end targets.

Surgical wards were modern in design with good provision of single room accommodation. The wards and departments were spacious, visibly clean and well organised. We saw evidence of regular audit with regard to infection control and cleanliness.

Patient care was personalised in line with patient preferences, individual and cultural needs and ensured flexibility, choice and continuity of care. Clear strategies were in place and implemented to improve the care of patients. For example, the appointment of link nurses, associate cancer physicians and engagement support workers.

The trust met the NHS operational target of 90% of patients waiting less than 18 weeks for treatment and rated second in the Yorkshire and Humber Region. The Trust was continuing to work on waiting times to improve services for patients.

Senior managers had a clear vision and strategy for the division and identified actions for addressing issues, the strategy clearly identified objectives for improving patient care and safety. There was good staff morale and staff felt supported at ward level. There was a culture that supported innovative practice and improvement and the trust had embedded a number of ways of working and improvements in practice that were improving quality of care and experience for patients.


There was no rota for the management of patients with gastrointestinal bleeds by an endoscopy consultant. This had not been resolved at the time of our inspection and staff identified this as a risk to the safety of patients.

Daily temperatures for the storage of medications were not all within the correct limits on all wards and were recorded outside the margins for the safe storage of medicines. No action had been taken to check whether records were accurate or whether there was a fault with equipment.

Trust data showed only 45% of complaints were closed within target in the surgical division.

Urgent and emergency services


Updated 20 June 2018

Our rating of this service stayed the same. We rated it as good because:

  • The service provided care and treatment based on national guidance such as the National Institute for Health and Care Excellence guidelines and the Royal College of Emergency Medicine’s clinical standards for emergency departments.
  • The department had a website called EM Beds which was used as a repository for the standard operating processes (SOPs), patient pathways, policies and guidelines in use across both hospital sites.
  • The service supported staff so they were competent for their roles. Nursing appraisal rates had improved since the last inspection.

  • Staff cared for patients with compassion, treating them with dignity and respect. Feedback from patients confirmed that staff treated them well and with kindness.
  • There were still issues with meeting national targets and standards in relation to patients waiting for treatment and admission to hospital, however the performance was generally better than the England average.

  • Learning from complaints and incidents was cascaded to staff and there was a clear focus on quality and continuous improvement.
  • Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff told us they were proud to work in the department.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. There was a clear management structure at directorate and departmental levels. The managers knew about the quality issues, priorities and challenges in the department.
  • The service had a vision for what it wanted to achieve and workable plans to turn it into action. The department had an education strategy for emergency nursing with a focus on educating, developing and growing a strong and competent nursing workforce.


  • There was consultant presence five days per week on a rota and weekends on a voluntary rota basis. Work was continuing to meet national guidelines of consultant presence for 16 hours per day.
  • At the time of our inspection the service was not recording or storing medicines appropriately. We found out of range fridge temperatures and gaps in recording of controlled drugs.
  • There was no suitable room to accommodate patients presenting with mental ill-health.
  • The service did not have registered paediatric nurses on shift. However, paediatric advanced nurse practitioners could be utilised from the paediatric ward and staff undertook two days paediatric training on induction, including basic paediatric life support.
  • The service did not always meet environmental audit targets for cleanliness or infection control. We found some areas on inspection that required deep cleaning.
  • Consumables in some areas of the department did not appear to be checked regularly and were expired. However, this was rectified immediately on site.
  • Staff understood the incident reporting process. However we found examples where staff did not always report issues as an incident, such as errors in the recording of controlled drugs or out of range fridge temperatures.



Updated 20 June 2018

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings.

We rated the service as good because:

  • Systems were in place for reviewing, monitoring, and sharing lessons learned from incidents.
  • Clinical outcomes for mothers and their babies at the trust had improved since our last inspection. Most women received 1:1 care in labour at the trust.
  • Rates of completion for maternity specific training often met or were on track to meet compliance targets set by the trust, and most maternity staff had received an appraisal.
  • Although not all staff were up to date with safeguarding training, procedures were in place and staff understood how to make referrals and escalate difficult or complex cases.
  • Areas we inspected were visibly clean. Survey and audit results showed good cleanliness, infection control and hygiene standards. Emergency equipment was available and checked routinely by staff. Policies and procedures were accessible to staff and the policies we reviewed were in date with version control.
  • Policies were in place to manage transfers from Huddersfield Birth centre to the Calderdale site, and required actions in the event of emergencies. The overall transfer time from the birth centre to the Calderdale site was in line with the national average for similar free-standing birth centres.
  • The management structure had clear lines of responsibility and accountability. There was a strategic vision for maternity services, and the head of maternity services sat on the trust board.
  • Capacity issues meant there was a risk of not identifying small for gestational age babies after 32 weeks gestation, and meeting demand for antenatal services. The risks were monitored and plans in place to address these issues.
  • Patient engagement had improved since our last inspection and the views and experiences of people who used maternity services were acted upon to shape and improve the service and culture.
  • Women and their relatives gave positive feedback about staff, and felt they had been included in decision making. Equipment, facilities and specialist midwifes and clinical teams were available to meet the needs of patients.
  • Since our last inspection, methods had been introduced to better understand and improve the culture within maternity services; these included anonymous staff surveys, workshops, and human factors masterclasses.
  • We saw participation in and learning from external reviews. For example, those undertaken by the Royal College of Gynaecologists (RCOG) and local Healthwatch groups.


  • Not all staff had received mandatory and safeguarding training.
  • The trust took an average of 38 days to investigate and close maternity complaints; this was not in line with the complaints policy timeframe to respond within 25 working days.
  • We were not assured that the current security arrangements for keeping babies safe in ward areas were adhered to.
  • The average breastfeeding initiation rate during March 2017 to February 2018 was 76%; this is lower than the England average of 81%.
Other CQC inspections of services

Community & mental health inspection reports for Calderdale Royal Hospital can be found at Calderdale and Huddersfield NHS Foundation Trust.