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Calderdale Royal Hospital Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 15 August 2016

Calderdale and Huddersfield NHS Foundation Trust is an integrated trust, which provides acute and community health services. The trust serves two populations; Greater Huddersfield which has a population of 248,000 people and Calderdale with a population of 205,300 people. The Trust operates acute services from two main hospitals - Calderdale Royal Hospital and Huddersfield Royal Infirmary In total; the trust had approximately 824 beds and 5,831 staff.

We carried out an inspection of the trust between 8-11 March 2016 as part of our comprehensive inspection programme. In addition, unannounced inspections were carried out on 16 and 22 March 2016.

We included the following locations as part of the inspection:

  • Huddersfield Royal Infirmary

  • Calderdale Royal Hospital

  • Community services including adult community services, community services for children, young people and families and community end of life care

We inspected the following core services:

  • Emergency & Urgent Care

  • Medical Care

  • Surgery

  • Critical Care

  • Maternity & Gynaecology

  • Services for Children and Young People

  • End of Life Care

  • Outpatients & Diagnostic Imaging

Overall, we rated the trust as requires improvement. We rated safe, effective and well led as requires improvement and caring and responsive was rated as good. We rated the Huddersfield Royal Infirmary and Calderdale Royal Hospital as requires improvement and community services as good.

Our key findings were as follows:

  • The trust had infection prevention and control policies, which were accessible, and used by staff.Across both acute and community services patients received care in a clean and hygienic environment.

  • Patients were able to access suitable nutrition and hydration, including special diets, and they reported that, overall, they were content with the quality and quantity of food.

  • The trust promoted a positive incident reporting culture. Processes were in place for being open and honest when things went wrong and patients given an apology and explanation when incidents occurred.

  • Staffing levels throughout the trust were planned and monitored. There were shortfalls within medical care, children’s services and adult community services however; it was addressing this through a range of initiatives including national and overseas recruitment.

  • Medical staffing numbers did not meet national guidance in the emergency departments across both sites.

  • The accident and emergency departments’ provision for paediatric patients was limited with only one paediatric qualified staff member on duty during our inspection across both sites and limited facilities available for children and young people.

  • Not all staff within children’s services had received safeguarding training at the appropriate level for their role in line with the requirements of the Safeguarding children and young people: roles and competences for healthcare staff Intercollegiate document (RCPCH March 2014).

  • Patient outcome measures showed the trust had mixed performances against the national averages when compared with other hospitals with some outcomes performing better and some performing worse.

  • The trust had consistently achieved the national standard for percentage of patients discharged, admitted or transferred within four hours of arrival to A&E in eight of the last 12 months. Between April 2015 and March 2016 the year to date percentage of patients achieving this target was 93.88% which was just below the target of 95%.

  • The trust had consistently achieved the national indicators for patients on the admitted, non-admitted and incomplete referral to treatment pathways.

  • The trust had a nurse consultant for older people and a learning disabilities matron. Across the trust 200 Matrons and Sisters had received training and were vulnerable adult’s leaders to ensure the vulnerable adult care principles and process were embedded into practice. This included care of patients living with dementia.

  • The estates and facilities team throughout the trust were focussed on improving the quality of patient care and experience and considered this when undertaking work to improve the environment.

  • Across the services we found a variable understanding from staff regarding consent and mental capacity.

  • The trust performance for responding to complaints within the relevant timescale was 48% against a target of 100%.

  • The trust had an overall vision which was underpinned by behaviours, goals and responses to support the delivery of the vision. The trust vision was “Together we will deliver outstanding compassionate care to the communities we serve.” The trust vision was supported by four ‘pillars’ of behaviours that were expected of all employees.

  • There were a number of concerns within maternity services which included feedback from patients during the inspection, the numbers of large volume postpartum haemorrhages (PPH), third and fourth degree tears, the antenatal assessment of mums to ensure they delivered in the appropriate setting and the ability to open a second obstetric theatre.

  • We found during the inspection that there were a number of patients on the clinical decision units (CDU) in the accident and emergency departments who had an extended length of stay on the units whilst waiting for a general inpatient bed.

  • It was difficult to determine how the service had planned services to meet the needs of local children and young people at Huddersfield Royal infirmary. There was no clear rationale or model of care for the services provided on the paediatric assessment unit.

We saw areas of outstanding practice including:

  • The development and growth of the ambulatory care service to support the hospital sites and meet local need. The trust had vulnerable adult’s leaders to ensure the vulnerable adult care principles and process was embedded into practice.
  • Engagement support workers had been appointed to provide engagement, socialisation and companionship, cognitive and physical support for patients with dementia and/or delirium. The team supported patients during the day with either group or one-to-one activities which promoted sleep at night. Through providing suitable engaging activities during the day, less 1:1 care was required during the day and night. This also helped other patients experience by reducing sleep disruption on the wards.
  • The trust had worked closely with local higher education facilities and offered an enrichment programme to ‘A’ level students to experience working in a hospital environment but particularly with patients living with dementia or experiencing delirium.
  • The development of NEWS and ‘Nerve centre’ technology to identify deteriorating patients for prompt care escalation and intervention.
  • The use by critical care outreach of the NEWS and Nerve Centre technology to drive effective identification of the deteriorating patient in ward areas. This supported early admission to critical care, and in turn better patient outcomes. The team could use the system to prevent readmission of critical care discharges.
  • A proactive, positive and energised discharge coordination team together with an integrated MDT working to provide care to the patient in the most appropriate environment.
  • Within community services multidisciplinary and multiagency working was completely integrated in some teams with staff having a good understanding of each other roles. This led to a seamless service for patients and there was a collective responsibility to meet patients’ needs in the community.
  • The diagnostic imaging department worked hard to reduce the patient radiation doses, and had presented this work at national and international conferences.
  • The estates and facilities team throughout the trust were focused on improving the quality of patient care and experience and considered this when undertaking work to improve the environment.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • The trust must continue to ensure at all times there are sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients’ dependency levels.

  • The trust must continue to embed and strengthen governance processes within the clinical divisions and at ward level.

  • The trust must ensure all staff have completed mandatory training, role specific training and had an annual appraisal.

  • The trust must continue to strengthen staff knowledge and training in relation to mental capacity act and deprivation of liberty safeguards.

  • The service must ensure staff have an understanding of Gillick competence.

  • The trust must continue to identify and learn from avoidable deaths and disseminate information throughout the divisions and the trust.

  • The trust must ensure staff have undertaken safeguarding training at the appropriate levels for their role. The service must also ensure all relevant staff are aware of Female genital mutilation (FGM) and the reporting processes for this.

  • The trust must ensure that systems and processes are in place and followed for the safe storage, security, recording and administration of medicines including controlled drugs.

  • The trust must ensure that interpreting services are used appropriately and written information is available in other languages across all its community services.

  • The trust must ensure that appropriate risk assessments are carried out in relation to mobility and pressure risk and ensure that suitable equipment is available and utilised to mitigate these risks.

  • Within maternity services the service must focus on patient experience and ensure women feel supported and involved in their care.

  • The trust must review the provision of a second emergency obstetric theatre to ensure patients receive appropriate care.

  • The trust must continue work to reduce the numbers of third and fourth degree tears following an assisted birth and the incidence of PPH greater than 1500mls following delivery.

  • The trust must review the admission of critical care patients to theatre recovery when critical care beds are not available to ensure staff suitably skilled, qualified and experienced to care for these patients.

  • The trust must continue to review arrangements for capacity and demand in critical care.

  • The trust must ensure that patients on clinical decision unit meet the specifications for patients to be nursed on the unit and standard operating procedures are followed.

  • The trust must ensure there are improvements to the timeliness of complaint responses.

  • The trust must ensure there is formal rota for the management of patients with gastrointestinal bleeds by an endoscopy consultant

  • The trust must review the model of care for the services provided on the paediatric assessment unit at Huddersfield Royal Infirmary.

In addition the trust should:

  • The trust should review the availability or referral processes for formal patient psychological and emotional support following a critical illness.

  • The trust should review the handover arrangements from the hospital at night team to the critical care team to ensure continuity of patient care across the hospital.

  • The trust should ensure that relevant staff have received training in root cause analysis to enable them to provide comprehensive investigations into incidents.

  • The trust should provide consultation opportunities and team collaboration in the development and completion of its business strategy and vision for end of life care.

  • The trust should ensure that children are seen in an appropriate environment by staff that are suitably skilled, qualified and experienced.

  • The trust should ensure signage throughout the HRI main building and Acre Mills reflect the current configuration of clinics and services.

  • The trust should ensure there is access to seven-day week working for radiology services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas


Requires improvement

Updated 15 August 2016


Requires improvement

Updated 15 August 2016



Updated 15 August 2016


Requires improvement

Updated 15 August 2016


Requires improvement

Updated 15 August 2016

Checks on specific services

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.

Maternity and gynaecology

Requires improvement

Updated 15 August 2016

Overall we rated maternity and gynaecology services as requires improvement.

Mandatory training figures were variable and figures were generally lower for medical staff and safeguarding training. Training was not provided on the mental capacity act and deprivation of liberty safeguards which left a gap in knowledge for staff.

We were concerned over the numbers of women experiencing third and fourth degree perineal tears and postpartum haemorrhage following delivery. This had been flagged on the maternity dashboard as being higher than the regional average.

Staffing on the gynaecology ward was often below the planned level. The recommended ratio of midwives to births and supervisors of midwives to midwives was not being achieved.

We received negative feedback from some of the women we spoke with, which reflected comments seen in some of the serious incidents and complaints data.

We were concerned that the risk associated with the opening of a second emergency obstetric theatre and subsequent theatre delays were not a focus within the service.


We saw the careful planning and support systems had been put in place when implementing the electronic patient record.

Handovers between staff were detailed and informative.

Clinical areas were clean and tidy with sufficient equipment to meet the needs of patients.

Care bundles and action plans had successfully reduced the number of stillbirths.

The preceptorship package for newly qualified nurses and midwives was comprehensive and on-going development of staff was supported through the ‘clarity’ project.

Staff spoke in a positive way about local leadership and visibility of the senior management.

Staff were patient focused and we observed compassionate care in the areas we visited.

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.

Urgent and emergency services (A&E)


Updated 15 August 2016

We rated urgent and emergency care as good overall because:

The department had information available for patients which included waiting information screens and department information in each cubicle.

There was good learning from incidents and complaints, including the sharing of findings and complainants were involved in the process.

The immediate leadership team were well respected by staff and we were told that they were approachable, visible and supportive.


During the inspection we had concerns around the use of the clinical decisions unit (CDU). Patients were being admitted for substantially longer than the 24-48 hours outlined in the trusts policy. There was confusion as to which medical teams were responsible for patients waiting for beds on inpatient wards were being treated on the CDU as well as ED patients.

Patient flow through the department was confusing and meant that patients could wait longer than the national 15 minute target for initial assessment. This meant that patients were waiting for potentially long periods of time for analgesia or assessment.

Staff shortages to both nursing and medical staff meant there was high usage of agency and locum staff. This had also affected training rates and mandatory training rates did not meet trust targets.

Provision for paediatric patients was limited. There was not a dedicated paediatric area and the department only had one qualified Paediatric nurse. Paediatric staff from ward 3 within the hospital could provide support, and if available would attend the department to manage the care of paediatric patients.



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.

Intensive/critical care

Requires improvement

Updated 15 August 2016

Overall we rated critical care as requires improvement. We rated the effective, responsive and well-led domains as requires improvement and safe and caring as good.

There was an inconsistent understanding of incident grading and reporting of incidents in critical care, there were processes to share learning from incidents however not all staff we spoke with were aware of this. Patient harm incidents were low and results for recent falls and pressure ulcers were displayed on a ‘how are we doing’ noticeboard.

Nurse and medical staffing was good at the time of inspection however we found areas of non-compliance with intensive care standards for all staff groups. Recruitment and retention of nursing staff had been challenging for the unit, however recruitment of nursing staff had been successful in 2015/16.

The unit submitted data to the intensive care national audit and research centre (ICNARC) case mix programme, and it was able to benchmark its performance against comparable units. Patient outcomes were generally good however; 41% of all patient discharges were delayed more than four hours after the decision to discharge.

Between January and March 2016 the theatre recovery unit had been utilised every week by critical care for admission of patients. This was not a safe arrangement; activity was not being planned, monitored or managed by the critical care senior team.

Thirty nine percent of nursing staff held a post registration award in critical care nursing and intensive care however national guidance recommends a minimum of 50%. There were plans for three staff to attend the course in 2016. In line with recent recruitment there was a high ratio of inexperienced nursing staff and an additional clinical educator had been appointed to provide support. Senior staff recognised that they needed to retain its current establishment of experienced nursing staff.

The vision and strategy for the critical care service was not shared or clear across the team. The senior team we spoke with from critical care and the surgical and anaesthetic directorate told us of the trust five year proposals for a single site unit in 2021 in order to improve achievement against GPICS (2015), however interim strategy or vision was limited to address some of the current issues in the unit

There was a governance structure in place under the surgical and anaesthetic division. We saw evidence in the management and divisional team meeting minutes that incidents and complaints were monitored and reviewed.


The unit was visibly clean, had good facilities and equipment for care of the critically ill patient. Infection control practices were good amongst staff and there was a low incidence of infection, better than national averages (ICNARC).

Care of patient’s nutritional need was good. The dietitian was an integral part of the team to ensure good standards of patient assessment and support. There was evidence of good multidisciplinary working. Medicines management and record keeping was also good in critical care. Staff had attended a medical device competency training programme for all items of critical care equipment and a tracheostomy training programme delivered by the critical care outreach (CCOR) team.

We observed caring staff. Patients and relatives we spoke with were positive about their experiences in critical care. We saw individual care plans and good documentation around risk assessment, and patients and family needs were also documented well. There was a low number of patient complaints in critical care.

We observed good teamwork amongst staff however reports of staff satisfaction were mixed from the 34 staff we spoke with. The majority (7 out of 9) of junior nursing staff in band and five and six roles we spoke with told us of issues around limited cascade and communication of information, a lack of investment in professional development of experienced staff and staffing issues which had caused a negative impact on staff morale, particularly in 2015. The senior critical care team had also identified these issues, held staff ‘listening events’ and had developed an action plan which they were making progress against at the time of inspection.

Services for children & young people

Requires improvement

Updated 15 August 2016

Overall we rated the service as requires improvement because:

Safeguarding training levels were far lower than the trust requirement of 100% compliance. Training in other areas, such as infection control, were also below the trust target.

There were examples of lack of oversight by leaders and the ability of staff to recognise safety issues, for example, resuscitation trolleys behind locked doors.

Investigations into incidents, prior to inspection, using root cause analysis were not always comprehensive and were poorly documented.

Action plans to mitigate risks and issues in the service did not demonstrate timely action and response.

Audit data showed that patient outcomes were worse than the England average.

The neonatal unit were not undertaking universal precautions to reduce infection control risks.

There were no facilities to support the needs of older children and adolescents.

Some parents said communication about their child’s care could be improved.


The service had a system for reporting incidents. Incidents were reportedly in a timely manner. Staff provided examples of lessons learnt from incidents; however, staff did not always get direct feedback when they had reported an incident. There was an electronic system in use which alerted staff to deteriorating patients and the need to monitor patients closely. This system was introduced following learning from a serious incident.

The trust was a pilot site for the Child Protection – Information Sharing (CP-IS) project, an NHS England sponsored programme. The aim of this project was to provide timely information regarding safeguarding concerns across health care providers.

The service had processes in place to implement NICE guidelines and other best practice guidelines. The service also participated in national audits. The service implemented local audits such as infection control audits.

There was evidence of multidisciplinary working across all the children’s services.

Throughout our inspection we saw patients and relatives treated with dignity, respect and compassion. We heard staff using language that was appropriate to patients’ age and level of understanding. All the patients and families we spoke with were happy with the care and support provided by the staff.

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.

Other CQC inspections of services

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