Calderdale Royal Hospital

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

At our last assessment we rated this key question good. At this assessment the rating remained good. This meant people’s needs were met through good organisation and delivery.

We looked for evidence people and communities were always at the centre of how care was planned and delivered. We checked the health and care needs of people and communities were understood, and they were actively involved in planning care which met these needs. We also looked for evidence people could access care in ways which met their personal circumstances and protected equality characteristics.

We have not awarded this service a score for Responsive.

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

The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Some OPD environments and services were designed to meet the needs of patients living with dementia. Staff took a structured approach to identifying and supporting people with dementia, mental health conditions, or learning disabilities from the point of referral. Staff flagged specific needs early where possible during the referral process to ensure appropriate planning and support. For example, the oncology navigator would flag up any GP referrals for people with a learning disability on their EPR system. The trust’s learning disabilities lead would accompany to support for their first contact with the service.

Hospital and department leads were committed to inclusive care. They had policies for patients who needed additional support to access information and services.

Managers ensured staff, patients, loved ones and carers could get help from interpreters when needed. Outpatients could translate self check-in screens and relevant appointment information into 28 languages.

Staff could provide interpreter services, large print or braille materials. Some clinic receptions could support accessibility for patients with hearing impairment through a hearing loop system. Signage was in place, and staff were encouraged to proactively offer this support.

98.4% of divisional staff (including non-clinical) had completed their Oliver McGowan statutory training tier one online e-learning for learning disability and autism. This divisional data could not be broken down to location specific information. This met the trust’s target compliance of 95%. This meant staff had the basic knowledge and skills to care for this patient group.

However, compliance for the practical tier 2 full day was compromised by lack of spaces and staff cover so they could have training days. Clinical staff did not meet the trust’s target compliance of 95% for tier 2. The directorate was on target to achieve Tier 2 compliance over the next 2 years aligned to the organisational trajectory. We heard about some encouraging service initiatives and development work to better meet the needs of people with autism or a learning disability (LD).

OPD staff also received bespoke training sessions around LD and autism. This formed part of their induction and preceptorship programs. They also covered this topic during learning disability week and with the trust-wide network of learning disability champions.

The trust had a lead learning disability nurse consultant who led improvements in provision and supported OPD staff in implementing reasonable adjustments for this patient cohort. They visited clinics to raise staff awareness, share advice and examples. Several clinics across the service had appointed THINK LD champions to provide support to all patients with LD. They wore a corresponding visible badge, were well known and available to colleagues.

The endoscopy unit demonstrated extensive service provision and ongoing development to support people with learning disabilities, including nine THINK LD champions. In addition, the gynaecology clinic was supported by a dedicated support worker who acted as a learning disability ambassador.

Staff could use several passports the trust had co-designed with service users and carers to support the delivery of person-centred care. This included a passport available for children and young people (CYP) with chronic, long-term and complex conditions. It provided clear, accessible information which supported personalised, family-centred care. This helped ensure individual needs, preferences, communication requirements and reasonable adjustments were recognised and consistently met across OPD services.

Staff could also access autism passports for CYP, as well as passports for young people and adults with learning disabilities to promote inclusive, person-centred care. Staff could help people or their carers complete these. They uploaded completed passports to the patient’s electronic record.

Passports ensured all OPD staff could access key information in real time for people with specific needs. This supported continuity, safety and a consistent approach to care delivery across the pathway. The EPR system’s learning disability flag supported OPD teams to identify this patient group. They could check if colleagues had completed passports.

Passports were comprehensive and included an ‘about me’ section. They also clarified people’s likes, dislikes, allergies, medications, any medical conditions, transitions into adult services and anyone involved in their care. We saw a partially completed child’s passport which confirmed their personal needs. Clinic managers shared John’s campaign for carers updates with their staff.

We also heard about the unit supporting an outpatient with severe medical phobia. Staff gradually built their service tolerance and accessibility to improve their clinical outcome after six months.

Care was not always joined-up and flexible.

However, the service understood the diverse health and care needs of people and their local communities, so care supported choice and continuity.

The service’s clinics did not always run on time and could keep patients waiting. We observed some consultant clinics running late and behind schedule.

During our two-day assessment, some outpatient department (OPD) clinic waiting times extended to between one and two hours, including drop-in phlebotomy services, ophthalmology (eye clinic), and the main OPD pharmacy at Calderdale. Some general OPD patients, as well as those waiting for prescriptions or support from the main OPD pharmacy, experienced waits of up to an hour beyond their appointment time. Gynaecology outpatient appointments were delayed by 30 to 45 minutes, despite patients having waited up to six months to access the service.

However, staff informed patients of any clinic delays upon arrival and kept them informed. Nursing staff in general OPD carried out welfare checks of patients in waiting areas.

After our onsite assessment trust leads told us actions were in place to actively reduce waiting times. For example, the eye clinic was reviewing appointment templates to ensure they reflected realistic consultation lengths and the growing complexity of cases. The clinic expanded its use of virtual reviews and consultant-led digital triage. This reduced unnecessary face to face attendances. These actions helped service leads respond to rising patient numbers year on year, and additional pressure on clinic capacity.

Clinics were being streamlined through more efficient batching of diagnostic tests such as optical coherence tomography and visual fields to minimise movement and waiting within the department. Leads also worked closely with diagnostics, medical photography, and booking teams to better match capacity with demand and identify bottlenecks early.

Leads were exploring the use of visible signage, such as whiteboards or digital displays, to show approximate waiting times. This would help manage patients’ real-time expectations and reduce the need for repeated enquiries.

Patients in most clinics were prompted to remind receptionists if they had been waiting over 15-30 minutes.

Consultants told us they could sometimes be delayed by needing extra time with a more complex patient.

Some clinics could facilitate increased capacity to meet extra demand. For example, during summer dermatology could offer patients out of hours clinics when referrals peaked. Gynaecology had run some ‘Super Saturday clinics’ for extra first capacity. They had plans in place for further clinics in the coming months.

Shortly before our assessment, leads identified opportunities to accommodate an additional appointment slot across all clinics. Nurse consultants used phonetic dictation to generate digital results letters, which could be sent to patients immediately. In dermatology, patch testing clinics previously required patients to attend three times in one week before medical review; however, by doctors completing the final reading on the same day, long waiting lists were reduced and patients required fewer appointments. In the eye clinic, staff were able to complete 20–24 rapid vision assessments in a morning using charts and specialist equipment.

The endoscopy team backfilled appointments. Three days before their appointment, patients received an auto-text message.

The pre-assessment team responded promptly to patient enquiries about medicines, pre-procedure drinks, and symptoms such as coughs or colds, with clinical staff contacting patients following escalation from reception staff.

The service did not always supply appropriate, accurate and up-to-date information in formats tailored to individual needs.

The department did not always send or share information with outpatients promptly. The blood and paediatric clinic had a backlog of over 400 outstanding appointment letters. Leads ensured clerical staff were reducing this backlog. Some patient information in gynae-oncology had been photocopied multiple times. This made the paper copies shaded and hard to read.

The department also did not always adhere to information governance principles. We found an ECG machine charging in the cardiology clinic corridor with patient details including date of birth and medical record numbers visible and accessible on the screen. Transport patient information such as names and hospital numbers from 5 September 2025 to 3 February 2026 was also accessible in a dark green paper folder at general OPD reception. We checked with staff the folder remained available overnight. This meant anyone could potentially view this data.

However, staff talked with patients, families and carers in a way they could understand. They used communication aids where necessary.

Staff provided patients with clear, written aftercare information and verbal explanations, and encouraged them to ask questions to support their understanding and ongoing care

Other patient information leaflets stored online could be tailored or personalised to meet people’s needs. For example, eye clinic information leaflets were printed with black text on a yellow background as this was easier to read. The endoscopy service had its own website with all the essential information to prepare patients for their procedure including bowel preparation videos. Women’s services and gynaecology outpatients could request information in another format or language.

Staff followed a guidance flowchart for handling calls asking for ‘missing’ GP letters. They would check if the letter was showing on their EPR. If not they would request this from a typist as a priority. This meant GPs were never lacking information from outpatient appointments.

Staff communicated all outpatient appointments using a digital-first approach. Patients could choose appointment letters in their preferred format. The trust had guidance on how patients could change their preferences as well as how to access and read digital letters. Their patient portal and the NHS App provided clear ways for patients to access appointment information. Step‑by‑step user guides were available to help patients navigate the portal. This all ensured timely and accessible delivery of information.

The trust had regular information to support people with managing their care and communication needs online, as well as links into GP practices. Appointment letters advised patients of their outpatient clinic location. Staff, volunteers and clear signage supported people to find their way around. All outpatient signage was designed to be easy to follow, using bold text and colour‑coding to support clear navigation. For example, in ophthalmology areas eye clinic signs and information leaflets were printed with black text on a yellow background. This was easier to read and supported patients with visual impairment needs.

Staff consistently recorded outpatient’s communication needs within their Electronic Patient Record (EPR). Once recorded, these needs, such as large print materials, or hearing loop access, were automatically visible to all colleagues across departments. This meant teams could prepare appropriately before appointments and provide patients with information in their chosen accessible format. Communication methods and tools were included as part of the trust’s VIP hospital passport for people with specific needs.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

Eight outpatients (including some complex), their families and carers we spoke with were very positive, satisfied and complimentary about the service and felt nothing could be improved.

Patients gave positive feedback about the service supported by staff. Leads told us feedback gained was valuable. We saw examples of recent thank you cards and positive online reviews. OPD staff collected patient feedback through digital surveys and the NHS Friends and Family Test (FFT) results. We saw a summary of the department’s survey feedback for the last 12 months. This divisional data was not broken down to location specific information.

Staff told us examples of changes as a result of patient feedback. For example, some patients found the department’s webpages difficult to navigate. They did not always contain the information they needed. As a result, IT support reviewed pages in collaboration with expert panel members. This ensured information was accessible, consistent, and easier to understand for people with different communication needs.

In children’s outpatients, some people highlighted the lack of sensory equipment. In response staff purchased a sensory box available for use both in the waiting and clinic rooms. Other people highlighted the lack of a disabled toilet for children attending the clinic. Staff would instead escort children to the toilets on the children’s ward. Signage was installed to make these arrangements clear to patients and their carers.

The outpatient management team were responsible for the oversight and management of complaint responses. They aimed to proactively prevent complaints through visible and responsive leadership. All formal OPD complaints were received through the complaints team. They were formally acknowledged within three days, aligned to NHS England complaint standards and trust local policy.

The Head of Complaints met weekly with the Associate Director of Nursing to review the dashboard and monitor key performance indicators. This meeting provided an opportunity to provide targeted support to investigators where concerns about progress were identified.

We reviewed three of the department’s recent complaints and their responses across both sites. One was from an endocrinology patient’s follow up appointment in December 2025. This concerned what they felt was a breach of their privacy and confidentiality. Another staff member unknown to the patient entered their consultation without identification or introducing themselves. Their consultation ended before they could explain visual symptoms or ask questions. The patient sought clarification on eight points in their complaint letter. The executive medical director’s response letter addressed all these. The responder adhered to the duty of candour and apologised.

OPD leads requested recovery plans to manage any deterioration in performance. OPD’s complaints performance was recorded through the trust’s Integrated Performance Report. An ongoing program of training and development supported investigators to manage complaints in line with expected standards.

The OPD directorate was included in the trust’s patient experience and involvement group’s (PEIG) annual work plan. Key areas of work during 2025/26 included orthopaedic outpatient insight, hand splinting service relocation and specific ‘waiting well’ insight activities aligned to NHS England’s reforming elective care plan.

Patient experience leads supported OPD teams to undertake their own insight‑gathering activities aimed at improving patient experience. They encouraged greater use of patient experience data through wider quality improvement programmes. Staff used an approach developed specifically for the Outpatient User Group Programme (OPUG).

OPD had examples of service user (OPUG) and patient participation groups. For example, the eye clinic advertised a local macular support group. We heard these were well attended and aimed to support ongoing service improvement.

The service could not always ensure people could access the care, support and treatment they needed when they needed it.

We found a lack of equity in access for some cross-site services such as phlebotomy and pharmacy provision. The pre-booked elective blood clinic saw very few patients during our assessment but had excessive demand for its OPD main pharmacy.

General gynaecology outpatients had a 22 week wait before their first pre-assessment appointment. Service capacity issues could occasionally impact their 62-day compliance with the cancer target. Staff told us their community diagnostics clinics helped them meet compliance.

However, clinics were accessible and adaptable to meet patient needs. We reviewed the department’s latest referral to treatment times for January 2026. The RTT performance showed sustained improvement throughout the year. The OPD remained on track to meet the improvement trajectory submitted to NHS England. Performance had risen steadily month‑on‑month from focused pathway management, strengthened planned access processes, and targeted operational actions to reduce long waits. This meant patients’ access to consultations and appointments had improved.

Leads monitored monthly OPD RTT performance. Staff had treatment plans in place for all 52-week breaching patients. Across all specialties (except ENT) 2025/26 plans included achieving 18-week compliance for all first to be seen appointments.

Some clinics had reduced RTT times and their waiting lists. For example, the hospital’s endoscopy service had digitalised their pre-assessment. Dermatology had a new digital imaging system. ENT worked with a contractor to support the management of their waiting list. This contractor provided weekend capacity using the trust’s estate. OPD had seen higher appointment slot issues in ENT and Gynaecology. In response leads planned ongoing work to reduce appointment slot issue wait times down to 14 weeks by March 2026. These improvements ensured people had greater access to these clinics.

Dermatology staff told us despite increased referrals, their digital imaging system helped them meet their two-week waiting target for outpatients on the skin cancer pathway. This system accelerated referrals, enabling GP‑submitted photos to fast‑track patients to theatre or discharge.

The OPD managers and head of planned access had a project underway to centralise all their division’s appointment bookings through a hub and spoke model to improve governance and oversight. This work captured patient’s person-centred needs and requirements using business intelligence tools.

OPD had safe discharge processes in place. Staff communicated all clinical decisions clearly in writing and stored them on the EPR. They kept GPs or referrers informed at each stage of the outpatient’s journey. Discharge occurred after documented clinical review. This ensured decisions were safe and in line with the patient’s best interests. Outpatients were never discharged solely due to capacity issues or administrative factors. There were systems for contacting absent patients.

The OPD complied with the Accessible Information Standard (AIS) and Equality Act 2010, supported by an updated trust policy. Systems ensured patients received information in a format suited to their needs. Staff identified and recorded interpreter requirements at referral, registration, or health questionnaires, promoting equitable access.

A reader panel reviewed OPD patient leaflets to ensure accessibility compliance. Digital access was enhanced via the patient portal, enabling access to letters and communication preferences in line with NHS England elective care standards. Ongoing improvements aimed to enhance navigation and communication, including exploring RNIB NaviLens technology and improved communication boards for patients with sensory impairments.

OPD leads supported wider access to treatment within the local healthcare community and in collaboration with other acute trusts, independent providers and their regional NHS ambulance service.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The service had an outpatients user group (OPUG). They had undertaken projects around health inequalities and sought patient engagement to reduce did not attend (DNA) appointments. Leads had also set up a theatre improvement group led by two band 6 staff.

The provider’s waiting list and access policy ensured outpatients had transparent and equitable access to NHS treatment. Leads proactively oversaw the elective waiting list. They applied established protocols for DNA management, active monitoring, and inter-provider transfers in accordance with organisational policy.

All the department’s DNA appointments triggered clinical review as per the trust’s elective care access policy. Staff managed first appointment DNAs according to national RTT rules. For example, the clock was nullified and restarted.

OPD leads tracked DNA rates through the trust’s Integrated Performance Report. DNAs were reported quarterly through a health equity lens focusing on overall trust-wide DNA rates. Rates were compared for patients with a learning disability, by ethnicity and those from the most deprived areas (IMD 1 and 2). Staff used the trust’s inequalities flag on their EPR system within maternity, paediatrics, outpatients and elective services. This aimed to ensure equity across all patient groups.

The Learning Disabilities Group undertook annual audits of patients not brought to their appointment. This divisional data was not broken down to location specific information. We reviewed the latest audit from September 2025. This covered 154 episodes across all specialities. Findings showed 15 out of 25 people were seen in clinic. Consultants followed the trust’s was not brought (WNB) policy and referred relevant people onto safeguarding. Improvements were noted since the previous year’s audit.

Leads reported any issues identified into the Health Equity Group as well as the Safeguarding Committee. The Nurse Consultant for Learning Disabilities rectified issues identified promptly from the audit and gathered intelligence to address themes. This included mortality data and learning reviews to help inform the national learning disability mortality review (LeDeR).

DNA rates were displayed on dashboards in most clinic areas. These were mostly below 5%. We reviewed the example of a speciality metric tracker in urology from April to December 2025. During these nine months all were within the target of 7%.

Managers monitored non-attendance and implemented actions to reduce missed appointments. They recognised that over 32,000 appointments were missed annually trust-wide and targeted patients with repeated non-attendance, considering vulnerability and health inequalities. Findings informed outpatient actions and patient engagement campaigns on appointment management and associated costs.

Staff ensured patients who did not attend appointments were contacted. They followed the hospital’s DNA process for patients who DNA their outpatient appointment. Leads knew the most common reasons given anecdotally.

However, the OPD did not formally capture reasons for missed appointment DNAs. The department’s DNA rate had slightly increased. They had 5 DNAs out of 283 referrals in June 2025 (1.8%) and 7 DNAs out of 241 referrals in September 2025 (2.9%). This divisional data was not broken down to location specific information.

The overall DNA rate for urology increased by 0.5%. For September 2025 the OPD’s overall DNAs (across all specialities) for people with learning disabilities remained slightly higher than the trust average of 6.2%. The ear nose throat (ENT) and audiology clinic’s DNA rate for January 2026 was 10.97%. Service leads had work planned to reduce this rate.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff supported patients to make informed decisions about their care.

The division had established a new paediatric gynaecology service. This was in response to patient feedback and an incidents review. Previously there was no dedicated service for people under (the age of) 14. This ensured young patients received appropriate, safe, and age‑sensitive care in an appropriate environment. The review highlighted the need for a dedicated and structured pathway for patients under this age, aligned with safeguarding and paediatric governance standards. The new clinic would run alongside paediatric outpatients. This ensured access to specialist facilities, appropriately trained staff, and safeguarding support. A gynaecology consultant led these clinics working in collaboration with the paediatric team. They provided joint care and expertise as required.