Calderdale Royal Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement.

This meant the effectiveness of people’s care, treatment and support do not always achieve good outcomes or was not consistent.

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care.

We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

We identified a breach of regulation 12; risk assessments were not always completed or reviewed and regulation 11; staff were not confident about consent and training was not meeting the trust compliance level for dementia awareness or learning disability.

We have not awarded this service a score for Effective.

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

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

Staff told us risks were identified at triage and could include safeguarding, cognitive impairment, pressure damage and falls. However, when we spoke with staff, observed the department and reviewed records, this was not always reflected in practice.

We reviewed 10 sets of patient records, including paediatric records. Our review showed that assessments were not always completed. Not all records documented pain scores, nutrition and hydration needs, falls risks, allergies or mental capacity.

Pressure risk assessments were not consistently completed. Records contained no evidence of assessment. There was no documented evidence of bed rail risk assessments.

Patients presenting with poor mental health needs did not have documented care plans. Some had prolonged stays with no recorded plans to support personal care, nutrition or hydration.

Staff told us compliance with physiological observations and escalation was monitored through daily retrospective audit. This had been previously identified as an area that needed improvement by senior leaders within the department. We saw no completed audits regarding this and therefore, we were not assured that there was sufficient oversight which meant patients could be at risk. However, we were told by leaders after the inspection, that audits had demonstrated observations were completed in 81% of cases.

The service aimed to triage all patients within 15 minutes of attending the department. We saw patients waiting beyond 15 minutes throughout our inspection, increasing the risk that deteriorating patients were not identified promptly and that delays in initial clinical oversight could compromise their safety. However, data we reviewed showed the median time to initial inspection was consistently better than the England average from October 2023 to August 2025.

Patients told us they felt some of the information they gave to staff was not considered. For example, patients told staff about time‑critical medicines, but this was not reflected in their care records.

We saw that staff identified and recorded some cultural needs, such as language and dietary requirements, and aimed to meet these needs. Families could stay with their loved ones, and relatives and carers told us they were involved in discussions and asked for information to help staff understand how best to provide care and support. Staff could also add flags to patient records to identify patients with additional needs or who might require additional support. This included alert flags for patients with allergies, mental health needs, people with learning disability, autism or dementia and we saw evidence of these being used.

We scored the service as 3. The evidence showed patients receiving evidence-based care. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them.

Staff and leaders were encouraged to learn about new and innovative approaches that could improve care and efficiency. The department also held regular safety huddles where changes to practice were discussed and highlighted to staff. Staff corroborated this when we spoke with them. We spoke with staff from a range of roles and grades, and all said they could access ED specific guidelines and standard operating procedures, including flow charts, when needed. Staff also told us their colleagues and senior team members were supportive and willing to share advice and experience.

The department had several clinical and referral patient pathways for clinical conditions which patients followed depending upon their presenting diagnosis, for example a stroke pathway and a sepsis pathway. These pathways supported staff to make sure patients received timely interventions such as scans and antibiotics. Staff also used the trust’s ED specific systems to follow the latest guidance and evidence‑based practice.

The trust had governance processes in place to make sure all changed or updated guidance and standard operating procedures were reviewed and implemented across the department.

Patients told us they were offered food and drinks however we were approached by three patients who told us they had asked for drinks and were still waiting. We informed staff who made sure drinks were eventually received. People we spoke with in waiting areas told us the only access to food and drinks was from vending machines, particularly overnight. We were concerned that vulnerable patients may not always receive food and drinks in a timely way. Patients’ nutrition and hydration needs were not always documented or met.

The Royal College of Emergency Medicine (RCEM) inter‑professional standards, which state that referrals must be accepted by specialty teams, were not always upheld. Most medical referrals could not move to ward beds quickly because no beds were available. Patients therefore remained in the ED, and the ED took responsibility for patients after referral. This meant the ED was managing patients who, under professional standards, should have been reviewed and managed by specialty teams elsewhere in the hospital. It further added to the pressures within the department.

The service worked well across teams and services to support people. They shared their inspection of people’s needs when people moved between different services.

We observed nursing and medical handovers during our inspection. Staff shared relevant and important information about patients with their colleagues. They understood the importance of handing over detailed information about patients’ needs and wishes, as well as clinical information such as the required frequency of observations and any outstanding tests. Staff could also access patient records to review information, including National Early Warning Score (NEWS) results.

The department was overseen by a nurse in charge (NIC) and an emergency physician in charge (EPIC) who kept an overview of the department and the patients and staff within. The NIC monitored availability of beds, acuity of patients, movement of patients to higher or lower dependency areas, staff cover and breaks and bed status outside of the department. The NIC’s role was to support flow through the department and liaise with other department in the hospital to make sure the ED ran smoothly. We observed the NIC several times over the inspection and found the staff covering the role were effective and experienced.

The department had access to several specialist teams, including the BLOSM team who support vulnerable people to attend ED at CRH and HRI), physiotherapists, occupational therapists and psychiatric liaison. During our inspection, we saw input from the BLOSM team, occupational therapists and acute liaison psychiatry. Multidisciplinary teams were involved in assessing patients’ needs. We saw examples of effective joint discharge planning, including collaboration between the mental health trust and ED staff to support the transfer of a patient to an inpatient mental health facility.

Although some specialties, such as acute liaison psychiatry and medical care, frequently attended the department, patients who required input from other specialty teams continued to experience delays. Specialty reviews did not often take place in a timely way following referral and often exceeded the 60‑minute professional standard. This delayed specialist care. The ED carried the risk for these patients and absorbed patient‑flow pressures for the whole hospital. We were concerned that delays at the front door meant some patients waited too long for care and treatment or received care in an environment that was not appropriate for their needs.

We saw good multidisciplinary working and observed respectful interactions between staff. Staff were visibly busy throughout the department but spoke positively about teamwork and support from colleagues and most leaders.

We also reviewed how coordinated the care pathway was for children and young people. The trust paediatric service was based at the CRH site. The paediatric ED had access to support from the ward, especially in case of emergency such as when resuscitation was needed. There were youth workers, physiotherapists and the safeguarding team. Input from these specialist services contributed to a coordinated paediatric pathway.

Staff told us they worked closely with the paediatric ward which helped maintain good communication and support. However, some staff told us there was sometimes reluctance from the paediatric ward to escalate and admit children from the paediatric ED.

The evidence showed a good standard of people being supported to live healthier lives. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

The department displayed relevant information promoting healthy lifestyles and sources of support on welcome boards throughout the department. This included videos and posters from national, regional, local and hospital campaigns. The information covered a wide range of needs, including both physical and mental health. Topics included cervical screening, smoking cessation, breast cancer screening, weight management, bowel cancer screening, community pharmacy support, mental health services, flu vaccination, stress and mood.

Patients could access support for domestic violence, sexual violence and other health and wellbeing areas such as homelessness and addiction via the BLOSM team.

The department had posters with digital codes on for people to scan with their phones to access health information, we saw evidence of how patients who may not be digitally literate, may have a learning disability or may not have the means to access digital information could access these resources in a comparable way, we saw printed information leaflets in patient areas.

We scored the service 2. The evidence showed how the department was monitoring and improving outcomes. The service monitored some of people’s care and treatment to continuously improve it however did had not participated in some national audits. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

We asked the department how the department was monitoring and improving patient outcomes. The department provided us with minutes of meetings where performance was discussed. For example, we could see that the number of patients waiting 12 hours or more had increased from 362 in April 2025 to 434 in December 2025. Bed occupancy had peaked in January 2026 at over 97% but had fluctuated between 93% and 97% between April 2025 and January 2026. The dashboard also measured several other metrics such as four hour performance, daily attendances, ambulance handover times and admission rates from ED. This information supported the department to monitor changes in activity over time and identify areas where improvement work was needed.

The department monitored the quality of care patients with sepsis received. This showed that in August 2025 timely antibiotic performance had fallen below the 80% target. We saw meeting minutes that showed there was ongoing quality improvement work to improve treatment patients received for sepsis.

We saw evidence the department was carrying out some quality improvement and clinical audit projects such as reducing inappropriate referrals and clinical record keeping however the evidence the trust provided contained limited information about ongoing audits being carried out in the department. Therefore, we were not assured that there was a robust programme of audit in the department.

For example, the department was not taking part in Royal College of Emergency Medicine (RCEM) audits. They told us this was a planned pause to make sure the correct systems were in place to ensure meaningful outcomes. However, we had concerns about how the department was assuring itself around the three audits, Time critical medications, Adolescent mental health and Care of older people as no alternative quality assurance work was taking place to monitor these. The trust had decided to continue participation in RCEM audits in the 2026-2027 round.

The trust told us that between January 2026 and March 2026 work was being undertaken to capture the resource needs of high priority audits to make sure they could be met and supported. All staff wishing to carry out an audit were being requested to register them.

We reviewed minutes of the department’s monitoring of patient mortality. This demonstrated that deaths in the department were reviewed by a senior doctor with actions for improvement identified and shared within the department as lessons learned.

Some staff told us they were not given protected time to carry out or participate in quality improvement work which impacted their ability to dedicate time and carry out improvement projects.

We scored the service as 2. The evidence showed some shortfalls in the consent process. The service did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

Nurses and other healthcare staff we spoke with said they did not feel confident in assessing capacity, and many were unable to articulate the principles underpinning capacity inspections, including how capacity is determined or how best‑interest decisions should be made especially for patients living with poor mental health, a learning disability or other neurodivergence. Staff were also unable to describe the legal implications of failing to assess capacity appropriately, either for patients or for themselves as practitioners.

We reviewed mandatory training and saw there was no specific consent training. Therefore, we could not be assured that people attending the department were always seen by staff with the skills and knowledge to explain consent or understand how to take and record consent appropriately.

Training compliance for dementia awareness remained below the trust target, with medical staff achieving 84%. Compliance for autism awareness training was also low. Part 1 stood at 71% for medical staff and compliance for part 2 was low for all staff groups, with nursing staff at 8% and medical staff at 6% compliance.

Medical staff compliance with deprivation of liberty safeguards training was 51% for level 2 and 79% for level 3, both below expected levels. Nursing staff fell just below the trust target of 90% for level 2 but exceeded compliance for level 3. This meant patients were at increased risk of receiving care from staff who did not have the necessary skills and awareness to recognise and respond to dementia‑related needs, autism‑specific requirements, or legal safeguards such as deprivation of liberty, potentially compromising safe and effective care.

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 or evidence staff had discussed the rails with the patients. This meant patients 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. This further restricted people’s independence and opportunity to consent to an aspect of their care.

Staff were supported by the trust safeguarding team for guidance around consent, mental capacity and best interest decisions making processes.

We reviewed the trust’s consent policy and found that it was in date at the time of our inspection and due for review in February 2026. The trust also had a Mental Capacity Act and Deprivation of Liberty Safeguards policy. This policy was also in date and due for review in March 2026.