Calderdale Royal Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At our last assessment we rated this key question good. At this assessment the rating has remained good.

We looked for evidence that there was an inclusive and positive culture within the service, where equality, diversity and inclusion were promoted and embedded in everyday practice. We reviewed whether staff felt able to speak up, raise concerns and contribute to improvement, and whether there were effective systems to support freedom to speak up.

We have not awarded this service a score for Well-led.

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

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff described parts of the organisational culture that affected how the service operated during busy periods. They told us that senior leadership presence at peak times often felt reactive, with decisions made in response to immediate pressures rather than through coordinated planning. Staff said this contributed to a culture where frontline teams were left to manage day-to-day challenges with limited proactive support. They felt that clearer direction, more visible planning and more consistent communication from leaders would help support a more positive and resilient culture.

The UEC division had a strategy programme and provided examples of how improvement programmes in the service contributed and linked into the overall trust strategy, supporting a more coordinated and informed approach to driving quality improvement across the organisation. The trust’s strategy for 2023-2028 included plans to reduce health inequalities, ensuring quality and safe care and improving care for children and young people.

Teamwork within the department was characterised by staff as strong and cohesive, with staff supporting one another well despite operational pressures. Staff consistently described strong multidisciplinary team (MDT) working. ED consultants were described as highly supportive, responsive to nursing escalation, and respectful of concerns raised. Nurses reported that when they escalated a patient’s deterioration or risk, medical colleagues acted promptly. We observed positive and caring interactions between staff and their patients and their relatives who used the service. We also noted good collaboration and communication between ED staff of all grades and disciplines.

Not all leaders understood the context in which the service delivered care, treatment, and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience, and credibility to lead effectively, or they did not always do so with integrity, openness, and honesty.

Staff told us they worked under sustained and significant pressure. They said staffing arrangements were not planned well enough to support safe and consistent care. For example, during the night there was no on‑site Matron or Band 7 leadership presence within UEC, which some staff felt left them without senior clinical oversight at times when they needed it most.

Staff told us that while UEC leaders were visible, their presence did not always translate into effective support. Some staff said that although leaders were seen walking the floor, the check‑ins they provided felt brief and did not consistently address the pressures teams were facing. Staff also reported that leadership input during peak times was sometimes reactive rather than coordinated, which limited its impact on patient flow and the day‑to‑day challenges experienced by frontline teams.

The most recent NHS staff survey indicated inconsistent experiences of leadership, particularly regarding communication, development and flexible working. Line management scores were slightly worse than peers, and staff reported valuing stronger appraisal and development support. In response, the department implemented additional management training focused on performance management, supervision and feedback.

Leaders told us they worked closely with their teams to support them, especially during times of pressure. This included visiting the department and working with colleagues and other departments to resolve challenges such as bed pressures and staffing issues.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff had access to Freedom to Speak Up (FTSU) champions in the department. The trust’s FTSU policy set out the process for raising concerns and how staff could contact the champions. Most staff told us they would use the FTSU route only if they felt they would not be listened to through usual channels or if senior staff were involved. Staff told us the FTSU process was promoted within the department, and they knew how to raise concerns using this route. None of the staff we spoke with had personally used the FTSU process. The trust told us between January 2025 and December 2025 there had been 2 FTSU contacts relating to ED, one relating to patient safety and one relating to worker safety.

When we spoke with staff about whether they felt able to raise concerns and if they felt listened to, we received mixed feedback. Some staff told us they did not always feel their voices were heard about issues affecting the running of the department or that their ideas for improvements were valued. Several staff told us they were not confident to raise concerns due to confidentiality or that their concerns would be acted upon.

Not all staff felt confident that their concerns would be taken seriously or acted on. Some described a culture where speaking up did not always lead to meaningful change and which made them feel their ideas and contributions were not valued. Others said they were unsure whether senior leaders were sufficiently visible or approachable for staff to feel safe raising issues. This showed that the trust had not created a reliably open or protective environment for staff to speak up.

Our review of trust board papers from January 2026 showed that in quarter 2 of 2025, Trust wide 34% of concerns were raised anonymously. This was significantly higher than the national average of 3%. This suggested that staff did not feel safe or comfortable raising concerns openly within the trust.

The Trust’s staff speaking up questionnaire showed only 56% of staff Trust wide knew who the FTSU guardians were. Not all staff in the UEC knew who the FTSU guardian was. The questionnaire also showed trust wide only 52% of staff, who had raised concerns, felt they had been addressed.

Staff completed a training module called “Speak Up”, with further modules for managers and senior leaders to complete. We were not provided with any staff compliance training figures regarding these modules.

The department had several formal and informal routes for staff to raise their concerns. The divisional management team met monthly to go through the current concerns and discuss ongoing actions. The action log was overseen by the FTSU team.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff we spoke with told us they thought everyone was treated as an individual, fairly and with respect. The department consisted of staff from widely diverse groups such as different ages, genders, cultures, religions and nationalities. We observed staff working together in a friendly and professional way.

The trust promoted equality, diversity and inclusion and supported several staff networks which ED staff could join if they wished. These included for ex armed forces staff, carers, international staff, race quality networks and Pride network. Staff we spoke with told us they were encouraged to be their ‘true selves’ at work. The trust also held awareness events for religious festivals such as Diwali and Ramadan.

Results from the NHS Staff Survey indicated that staff from black and minority ethnic backgrounds continued to report poorer experiences than white staff. This suggested the trust’s approach to equality, diversity and inclusion was not consistently effective in creating a workplace where all staff felt equally respected and supported.

We reviewed data on the Workforce Race Equality Standard (WRES) within the NHS staff survey 2025.

This showed that across the trust 26% of white staff said they experienced abuse from patients, relatives and the public whilst for staff of other ethnicities this was 31%. The percentage of white staff experiencing bullying from other staff was 18% whilst for staff of other ethnicities it was 24%. Other results showed 52% of all other ethnic groups believed the organisation provided equal opportunities for promotion or progression. The percentage for white staff was 61%. There was a further discrepancy for staff experiencing discrimination from a team leader, manager or colleague with the percentage for white staff at 5% and for all other ethnic groups at 14%.

We also reviewed the Workforce Disability Equality Standard (WDES). These showed staff with a disability or long term condition (LTC) were more likely to be harassed, abused or bullied by patients, their relatives and the public (34%) than staff without (35%). Staff with an LTC or illness were more likely to experience harassment, bullying or abuse from managers (11%) compared to those without an illness or LTC (7%). Further, staff with an LTC or illness were more likely to experience bullying, harassment or abuse (22%) compared to those without (14%). Staff with a LTC or illness were also less likely to believe the organisation provided equal opportunities for career progression (54%) compared to (61%). Participants in the survey were also asked if their employer had made reasonable adjustments to enable them to carry out their work. There were 520 respondents to the 2025 survey, of whom 73.65% said they had. This was in line with the national average and an improvement over time.

The data showed an increase in the percentage of staff with a long-term condition or illness who felt satisfied with the extent to which their organisation valued their work. There was also an increase in the percentage of staff who said their employer had made reasonable adjustments to enable them to carry out their work.

We scored the service as 2. The evidence showed some shortfalls in the governance, management and sustainability of the department. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. We identified breaches of Regulation 17 Good Governance.

Clinical leaders recognised the risks in the department, but staff told us change was slow and didn’t always happen as quickly as needed due to limited resources and capacity. Staff also told us leaders were visible and although the department operated within OPEL (Integrated Operational Pressures Escalation Levels) and had a surge and escalation plan, staff told us they did not feel that these were impactful.

We found a slow pace of change in addressing issues highlighted at previous inspections. Concerns regarding the recording and administration of medicines and outstanding ligature risks had been raised before, and we continued to see the same issues at this inspection. This did not give us assurance that identified problems were acted on within an appropriate time frame or that governance systems were driving improvement.

The service did not meet its own mandatory training target of 90% for medical staff. Compliance across all modules was below target. This meant the provider could not be assured that medical staff had the up‑to‑date skills and knowledge required to deliver care safely. Leaders were aware of the issue but had not taken effective action to improve compliance.

Governance arrangements included regular safety, audit and quality meetings. Learning from incidents, complaints and mortality reviews was shared through monthly morbidity and mortality meetings. Morbidity and Mortality (M&M) meetings were held at department level. These meetings provided a safe and non‑punitive environment for clinicians to review adverse outcomes, medical errors and patient deaths, with the aim of improving standards of care and preventing future issues.

Risks were recorded on the trust‑level risk register and were rated according to likelihood and consequence. The trust sent us the most up to date register there were nine risks recorded relating to staffing, pharmacy input, waits in and flow through the department and major incident compliance. The risk register detailed actions and mitigations in place to manage risks. Staff and leaders at all levels demonstrated an understanding of the key risks in the emergency department. However, entries did not include the date risks were added, limiting assurance that concerns were addressed promptly. We discussed the highest risks with the leadership team who talked us through the work the department was doing to reduce the number and impact of the risks.

Staff had opportunities to raise concerns about risks they identified within the department, and there was a process to ensure these concerns were reviewed and added to the departmental risk register when appropriate. Risks were discussed across management levels, and staff knew who was responsible and accountable for specific risks.

Staff had access to major incident and emergency policies. The trust took immediate action following inspection feedback, including drafting new standard operating procedures for waiting room management, patients who left without being seen, and oncology and haematology patients receiving cancer treatment. The department also had business continuity plans for events outside its control, such as severe weather, infectious disease outbreaks and information technology failures. There was also equipment in place to respond to major incidents such as chemical spills.

All staff we spoke with were able to describe how they made notifications to external bodies such as the local authority for safeguarding issues and to the UK Health Security Agency for notifiable illnesses.

Leaders told us the organisation had a Safeguarding Committee, which provided oversight of safeguarding performance at divisional level. Meetings were held bi‑monthly. We heard about the Safeguarding Operational Group which had been recently restructured to enhance its operational relevance and ensure effective front line engagement. Meetings were held quarterly and had been operational for over 12 months. Staff reported positive feedback regarding its relevance, usefulness and focus.

The safeguarding adult’s policy was due for review in December 2025 and was scheduled for committee approval and board sign off in February 2026. The children’s safeguarding policy was due for renewal December 2027.

We scored the service as 3. The evidence showed a good standard of partnership working. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Leaders understood their responsibility to collaborate and work in partnership so that services operated in people’s best interests. They shared information and learning with partner organisations and worked with them to improve the safety and quality of care. The department collaborated with a range of stakeholders including other NHS Trusts, Healthwatch and the local NHS ambulance trust to support and improve joined‑up care. For example, they had recently collaborated on a piece of work to support a high intensity user group to avoid attending hospital when they didn’t need to.

Staff told us they liaised frequently with ambulance staff to review issues, concerns and opportunities for improvement between services. For people experiencing a mental health crisis, the department worked closely with the local mental health trust to support a joint approach to inspection and care. The department also worked with the local police and local safeguarding hubs. Staff shared information appropriately to support safeguarding, promote consistency of care and ensure concerns were identified and acted on.

The trust was also progressing a wayfinding project, working with governors and key stakeholders, including members of the Visual Impairment Group, to improve how people find their way around the hospital sites, particularly routes between the UEC department and other departments. Directions at the time of our inspection were confusing.

People’s views and experiences were gathered and used to shape and improve the service and its culture. This included feedback from people across different equality groups, people using the service, and those close to them. The trust provided examples of how feedback had informed improvements in the department. Direct patient quotes were sometimes used to help staff understand the impact of people’s experiences.

Staff told us there had been a change to ambulance provision after 1am and private ambulances were no longer used. The impact of this was patients waiting longer to be transferred to the correct place for their ongoing care. It also impacted the flow of the department as bed spaces remained occupied until the patient had left the department.

We saw evidence of initiatives developed with other agencies, including organisations from the voluntary and community sector. These demonstrated effective multi‑agency collaboration. Initiatives included joint work with housing services, mental health teams, addiction services and local authorities to support vulnerable people, families and young people.

We scored the service as 2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome, and quality of life for people. They did not always actively contribute to safe, effective practice and research.

We found the service had repeated breaches of the Regulations. Leaders had previously been told what needed to improve, but not all required changes had been implemented. Because past issues had not been addressed, risks to people remained. This showed the service had not demonstrated the ability to learn from mistakes, sustain improvements or embed safe and effective ways of working.

Systems to check and monitor quality were not always effective. Although audits were carried out, they did not always identify all risks, or they did not lead to meaningful action. For example, hand hygiene audits showed an average compliance rate of 99% between January and December 2025. This did not reflect what we observed in practice.

Staff were encouraged to take part in new initiatives and told us leaders welcomed their ideas for improving the department. However, some staff said it was difficult to take part or lead on new initiatives because of workload pressures in the department. They also reported that suggestions were not always acted upon and did not feel listened to. They told us they did not receive feedback about why suggestions and innovations were not carried forward which left them feeling demotivated.

The service provided examples of improvement to systems to manage patient movement through the hospital. This included the opening of the USDEC, which had improved flow, reduced pressure on the UEC, and helped improve timely access to care.

We were told about quality improvement governance meetings which were attended by senior staff and focused on quality, patient safety, and service improvement. The department was looking to introduce a pre‑meeting to encourage wider staff engagement and increase submissions of clinical audit ideas.

A series of lead roles were being developed, including a lead for quality improvement, though this role had not yet been filled at the time of the inspection.