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 assessment we did not rate effective. At this assessment the rating was good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

We looked for evidence people and communities had the best possible outcomes because their needs were assessed. We checked 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 leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

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.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff identified and assessed patient’s pain using recognised tools. They gave pain relief in line with individual needs and best practice. Clinical staff used a range of tools and resources to assess, and monitor referred patients’ level of pain.

OPD staff used different clinical tools across services. Tools were based on national guidance and treating clinician’s judgement based on their best available information. Clinical staff in both the paediatric and adult diabetes services could extract data remotely around blood glucose monitoring (BMs) for remote review and control. This allowed earlier, targeted interventions based on real time data. Another digital clinical tool staff used in outpatients was their Frontline Ownership audit tool data collection. This helped ensure they were cared for in a safe environment with IPC-practice compliant clinicians. Patients could access timely pain support including same week appointments when needed for clinical review. The service offered some out of hours evening clinics for lower risk patients to meet local demand.

Staff identified and documented any communication and physical support needs patients had. They used the electronic patient records (EPRs) database to flag any alerts or special requirements patients had.

Staff met the information and communication needs of patients with a disability or sensory loss. The OPD had specific pathways in place for patients with disabilities, dementia, mental health conditions, and sensory impairments. People with mobility issues were escorted by OPD or local ambulance service staff to waiting areas and clinic rooms.

Most OPD waiting areas had a water dispenser, jugs and cups available, a café or vending machines nearby. We saw support staff helping outpatients with drinks.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff followed up to date policies to plan and deliver high-quality care according to best practice and national guidance.

The gynaecology service had a long-running enhanced recovery programme. This included the physiotherapist, nurse and theatre team. This had reduced their proportion of patients with cancer to 5% of their total referrals.

The colposcopy service operated in full alignment with the NHS Cervical Screening Programme (NHSCSP) and British Society for Colposcopy and Cervical Pathology (BSCCP) standards. All staff’s clinical activity followed nationally approved, evidence‑based protocols. This ensured safe, consistent, and high‑quality care.

OPD had examples of evidence-based practice which supported clinical interventions and innovations. For example, the paediatric outpatients team had accelerated delivery of hybrid closed loops (HCL) techonology to children. Within 12 months, their caseload of patients on a HCL pump improved from 15% to 78%. As a result, they gained positive qualitative feedback from families and saw improved outcomes. Leads shared the positive impact on children and their families with other trust services by completing a digital story. This was in line with the NHS England 5-year plan for children to be prioritised around the management of patients and people with diabetes.

We also read about improvements in children’s outpatients spirometry. Specialist leads delivered this clinic in line with NICE guidance. This ensured evidence-based assessment and management of children of children and young people with respiratory conditions.

Access to the service was guided by the provider’s waiting list and access policy, ensuring that prioritisation was based on clinical need and aligned with patients’ rights under the NHS Constitution.

Managers and clinical specialists identified changes to national guidance. The access policy integrated national guidance including NHS England’s revised model and Evidence-Based Interventions (EBI).

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff held regular and effective multidisciplinary team (MDT) meetings to discuss patients and improve their care. OPD clinics held daily MDT safety huddles. Staff could dial in virtually if they were elsewhere. We saw notes from huddles included a proforma agenda of safety checks, staff absences, recent incidents, any clinics running late, learning and actions required, as well as a positive thought for the day. Huddles allocated the daily nurse in charge and fire warden for each clinic.

We observed good MDT working. For example, the fracture clinic’s medical team shared their workload evenly to care and treat 60-70 outpatients a day. OPD leads and staff maintained close working relations with other teams such as diagnostic imaging departments and analgesia medicines prescribing.

Consultants, nurses and healthcare staff worked together to care for patients, and provided effective clinical care. Preoperative assessment (POA) staff assessed all outpatients against the hospital admission criteria. They assessed if a referral was escalated to an anaesthetist for further review. Based on the outcome, the patient could be referred to the hospital’s MDT. This comprised ward nurses, preoperative assessment nurses, physiotherapist, head of clinical services and theatre staff. The MDT considered if patients could be treated safely and all appropriate services provided.

Consultants could make appropriate referrals to other teams if patients required additional support. Consultants were complimentary about their working relations with OPD staff.

Nursing and support staff were flexible and could mostly cover each other’s clinics. The gynaecology service offered outpatients nurse-led clinics, mainly by phone. General OPD also held phone clinics offsite at times which suited their patients.

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.

Staff assessed patient’s health at every appointment. They provided support for any individual needs. Clinical staff working in outpatients and pre-operative assessment (POA) were key to the hospital’s patient reported outcome measures (PROMs) programme. They worked hard to ensure outcomes showed continuous improvement and were submitted by the deadline.

The service had relevant information promoting healthy lifestyles and patient support in waiting and reception areas. Staff engaged with outpatients to actively encourage healthier lifestyle choices. For example, they gave patients information leaflets with QR codes to access health information and advice.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

We reviewed OPD performance from the 15 January 2026 trust board papers. The service’s total first attendances and procedures undertaken activity was above planned levels for November 2025 compared to the 2025/6 activity plan standing at 101%. This was a slight increase from activity levels seen in October 2025.

Leads had ongoing work to improve how OPD procedures coding was captured. Some specialties like gynaecology and urology had seen a positive shift from OPD attendances to procedures in their year-to-date position.

OPD staff monitored their effectiveness of care and treatment. They were reminded to complete audits at the hospital’s daily multidisciplinary safety huddle. Managers and staff participated in a monthly audit programme.

Staff used audit findings to make improvements and achieve good outcomes for patients. They conducted audits as part of their clinical audit programme. This included monthly cleaning and handwashing audits. There were actions arising from the audits.

Clinical staff conducted clinical audits quarterly. In the 12 months before our assessment, OPD services had 20 audits underway. 10 of these were at the data collection stage. This divisional data could not be broken down to location specific information. We saw action plans were embedded within the trust’s standard clinical audit documentation. Leads recorded all clinical audits with the trust’s clinical audit and effectiveness team. This ensured each audit was appropriately logged, monitored, and subject to the correct governance processes and oversight.

The service told people about their rights around consent and respected these when delivering person-centered care and treatment.

Patient notes were comprehensive and stored securely on their electronic patient records (EPR) system. Staff clearly recorded consent in patient notes. They gained written consent from outpatients when needed. For example, we saw written patient notes where consent was gained for a proposed surgical procedure in the department by a medical staff member.

Staff understood the relevant consent and decision making requirements of legislation and guidance, including the Mental Capacity Act 2005. When people lacked the mental capacity to make a decision, staff ensured best interest decisions were made in accordance with legislation.

Clinics had processes in place for outpatients with any mental capacity issues. Experienced staff nurses on duty pre-planned most of these patients. Staff could flag and identify any patients with fluctuating capacity on their electronic patient records system.