Calderdale Royal Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

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

The service had a proactive and positive culture of safety, based on openness and honesty. Managers listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

OPD staff had a good reporting culture where they felt safe and encouraged to report incidents, concerns, near misses, and feedback. OPD staff knew what incidents to report and how to report them.

Staff raised concerns, reported and investigated incidents and near misses in line with the trust’s incident management policy. The policy provided a clear and consistent approach to the reporting, investigation, and management of all OPD incidents. This ensured the department could provide a safe environment for patients, staff, and visitors.

Managers debriefed and supported staff after severe or distressing incidents.

The division had one never event in the 12 months before our assessment. This was a documentation error which caused no harm in July 2025. We saw that it had been managed in line with trust policy which included compliance with their professional responsibilities under duty of candour.

The service could evidence changes made after feedback. Learning responses for any patient safety event were tailored to each case, with person‑centred care at the core of continuous improvement. During our assessment all OPD clinic areas had 222 incidents open, under review or pending. However, of these only six were graded as moderate harm and two as severe harm. From November 2025 to January 2026, OPD staff reported 21 medicine related incidents. 81% or 17 of these related to medicines management in the OPD pharmacy. None of these were recorded as causing moderate or severe harm. The department monitored and investigated all medication incidents and errors in depth.

Staff received feedback from both internal and external incident investigations.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service worked to improve pathways and continuity of care for outpatients through joined-up clinics. There were safe and standardised referral pathways into the department, as per the trust’s elective care access policy.

Patient lists were kept up to date in a key performance management system, so no one was missed or managed outside the proper process. A specialist team also used automated tools to check the data and fix any errors.

Administrative staff booked outpatient appointments according to waiting time. This helped ensure fairness and safety.

Staff adhered to the trust’s right patient, right clinic, right time initiative. This ensured before any OPD consultations began, staff checked all outpatients’ full name, date of birth and address.

We reviewed 8 sets of records for gynaecology outpatients. The records were comprehensive, and staff could access them easily.

Staff used local safety standards for invasive procedures (LocSSIPs) during procedures and included them in patient notes. Comprehensive chaperoning proforma was also included. They used a well embedded electronic patient records (EPR) system. Nursing and clinical staff told us the system was accessible and user friendly. They emailed patients on the system to clarify any missed appointments.

Records were stored securely. The hospital had a back-up system to ensure patient records’ security.

Outpatient admission, inclusion, and exclusion criteria were clearly defined in alignment with the hospital’s latest statement of purpose and the NHS e-Referral Service (eRS) Directory of Services.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff received and kept up to date with training specific for their role on how to recognise and report abuse. Staff were appropriately trained in line with the intercollegiate guidance. During our assessment safeguarding training compliance for outpatient nursing staff was 100%. This divisional data could not be broken down to location specific information. This included the provision of safeguarding supervision. In addition to the role specific requirements, supervision was provided to support individuals on a case-to-case basis.

All registered clinical staff had completed the face-to-face level 3 module. This meant OPD staff overall were equipped with the required knowledge and skills to identify, respond to, and escalate safeguarding concerns appropriately.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. They followed processes supported by several trust policies to guide them.Staff had easy access to key safeguarding information, documents, and referral processes on their intranet. This included access to specialist safeguarding support and advice from the trust safeguarding team. We saw staff had contact details for trust and local authority safeguarding teams. The trust’s patient management system had flags staff could use for patients with allergies, reasonable adjustments, learning disabilities or autism. Lower band staff could also ask their nurse in charge or manager for advice or guidance.

Hospital and OPD leads were committed to ensuring all staff were trained in identifying risks to patient safety. Staff reported any safeguarding incidents in outpatients through a bespoke digital system. They could raise awareness of any ongoing safeguarding concerns on individual electronic patient records (EPRs) using flags and alerts. This prompted staff to exercise professional curiosity.

Safeguarding policies applied for paediatric and vulnerable people in OPD areas. Staff considered outpatient’s non-attendance in a risk-aware context and would follow up and flag to try and contact all DNAs.

Staff knew what action needed to be taken when someone went missing or were at risk of going missing as per the trust’s missing person policy. The policy had flowcharts staff followed, and referenced the Herbert Protocol. This is a UK initiative that helps carers record key details—like routines, usual places, and a recent photo—so police can quickly act if a vulnerable person goes missing.

All staff reported that the learning disability lead nurse and safeguarding team were responsive to concerns. Staff described an example where safeguarding support was promptly provided to an outpatient, and noted that the trust’s named safeguarding nurse had developed and shared a brief update for OPD staff on the Mental Capacity Act and Deprivation of Liberty Safeguards for young people aged 16–17

Staff followed relevant provider and hospital adult safeguarding and chaperone policies. They ensured patients were comfortable with a male or female nurse. This helped them safeguard any adults at risk of abuse or neglect. Chaperone information was displayed throughout OPD areas. Most patients we asked knew they could request this if needed. Staff covered female genital mutilation (FGM) guidelines as part of their safeguarding training.

We spoke with gynaecology clinical and support staff regarding safeguarding processes for paediatric patients within the department. Staff told us that young people aged 16 and 17 years, including those accessing the termination of pregnancy service (TOPS) or early pregnancy unit (EPU), were seen face-to-face in the gynaecology clinic. Patients under the age of 16 were reviewed by a gynaecology consultant within paediatric outpatient services.

Staff explained that any young people requiring admission were transferred to a gynaecology ward, where paediatric support was available. A TOPS nurse completed a safeguarding proforma and referred all outpatients under the age of 18 to the hospital safeguarding team for review.

We were informed a paediatric transition nurse was in post. They supported young people transitioning from children’s to adult services at the age of 18.

Staff told us that assessment of Gillick competence was undertaken by consultants. At the time of our assessment, the department was reviewing its safeguarding supervision arrangements and discussing improvements to referral processes.

All eligible OPD employees had the required pre-employment checks. For example, they were disclosure and barring service (DBS) compliant and held valid checks appropriate to their role and level of patient contact.

However, we found no information on domestic violence in waiting areas or toilets.

The trust could not breakdown the latest safeguarding training compliance for medical staff. This compliance sat within specialties, as none were line managed within the OPD directorate.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

However, staff did not always check resuscitation trolleys or position them accessibly.

We found the cardiology paediatric trolley missed five checks during a nine-week period from 1 December 2025 to 4 February 2026. This trolley was also visibly dusty. This meant in the event of an emergency, paediatric life support-trained staff could potentially be delayed accessing life-saving equipment.

Resuscitation trolleys in some services such as the eye clinic, ear, nose and throat (ENT) and gynaecology were stored in clinic procedure or treatment rooms instead of communal areas. This meant emergency response staff could potentially be delayed accessing trolleys in a medical emergency. Door signs stated they should not be locked when shut, so crash teams could access them easily. This could potentially compromise outpatient privacy, dignity and confidentiality if the trolley needing collecting mid-appointment.

However, trust leads took prompt action to address these issues. After our onsite assessment they confirmed all resuscitation trolleys would be stored in easily accessible locations across the outpatients service.

Staff responded promptly to any sudden deterioration in a patient’s health. All staff we asked knew the procedure if someone collapsed or suffered a cardiac arrest. Relevant staff were trained to use live-saving equipment.

Staff knew about and dealt with any specific risk issues. They individually assessed all patients to ensure a safe and appropriate clinical environment. For example, they completed thromboprophylaxis assessments to manage any identified bleeding risks for gynaecology patients.

Nursing and support staff completed appropriate risk assessments for patients.

Shift changes and handovers included all relevant information to keep patients safe.

All staff understood the department’s eligibility criteria. They would confirm any discrepancies with their managers.

OPD staff routinely updated risk assessments, and reviewed incidents through hospital governance meetings.

The service could not detect and control all potential risks in the care environment. Leads could not always ensure equipment, facilities and technology supported the delivery of safe care.

Staff did not always carry out safety checks of specialist OPD equipment. Medical devices were not always calibrated at the point of service. We identified environmental and equipment storage issues across outpatient clinics. In cardiology, some equipment, including Cardio 2 and ECG machines, had not undergone safety testing for two to three years. We also saw a visibly dirty ECG machine charging in a corridor. This meant we could not be assured the equipment was safe for patient use. This was a breach of regulation 15(1)(c) around premises and equipment.

Oxygen cylinders in cardiology were stored unsecured on the floor and not kept in wall-mounted cages. This posed a risk of injury and created a trip hazard for staff, patients, and visitors.

Some clinics and pharmacy areas also lacked appropriate facilities. For example, the main OPD pharmacy had insufficient seating for waiting patients, including those using mobility aids. As a result, corridors were obstructed, limiting access for staff and visitors.

Staff did not always check resuscitation trolley top drawers daily, completed weekly checks and updated records. We reviewed the trolley checklists and contents across all outpatient clinics. Not all had completed equipment or dates.

We found inappropriate storage of sterile equipment across several clinics. In gynaecology, some sterile equipment was stored in a sluice area next to a sink, and sterile kidney dishes were stored on the corridor floor under a table. In cardiology, an open box of sterile cleaning wipes was stored on the floor of a utility room. This increased the risk of contamination and meant items could become non-compliant if exposed to moisture.

We also found poor storage of clinical supplies. In gynaecology, different sizes of personal protective equipment (PPE), such as gloves, were stored in filing cabinets, and speculums were stacked on corridor tables. Other clinics, including cardiology, stored equipment supplies in corridors. This resulted in cluttered areas and increased the risk of obstruction.

We fed these concerns back to the clinic managers. Trust leads took prompt action to address these storage and bottleneck issues. After our onsite assessment the gynaecology clinic reviewed all items being stored. They reviewed if levels of supplies kept in the area could be reduced. Additional storage units would be procured if required to enable appropriate storage for supplies.

Staff did not always dispose of clinical waste safely. We saw OPD pharmacy waste was stored in large bins inside unsecured gates. This meant it was potentially accessible to anyone.

However, the design of the environment followed national guidance. Signage and directions to outpatient department clinics and areas was easy to follow. Visiting and first-time patients we asked knew where to arrive and park. Trust teams had conducted engagement work within OPD hospital areas. This involved them asking patients and visitors their experience of navigating the site. This would inform their proposed wayfinding and signage strategy with new artwork showing the planned new build.

Most clinic waiting areas displayed dashboards with up-to-date information.

All OPD areas had their own resuscitation trolley located near to waiting areas. Trolleys included child-specific equipment in clinics which saw and treated paediatric patients.

Managers could request additional resources to ensure or promote the quality of care and treatment.

OPD staff followed fire safety precautions and met training compliance. This ensured they worked in a safe environment. All staff undertook e-learning and face to face fire safety training. This training was included in their site induction and refreshed yearly. Fire drills were completed twice a year to ensure compliance with the fire safety processes detailed in the manual. Fire extinguishers were serviced and ready for use.

The service and all clinic areas had designated fire incident officers onsite during opening hours. Staff we asked knew fire procedures and how to direct patients and other visitors to safely exit the premises.

The service had enough suitable equipment to help staff safely care for patients. No clinics had been cancelled due to a lack of available equipment.

Sharps containers were signed, dated and not filled above the line. The trust had an in-date policy for prevention and management of clinical sharps injuries and exposure to blood and high-risk body fluids.

The service ensured there were enough qualified, skilled and experienced nursing staff. They received effective support and supervision. They worked together well to provide safe care that met people’s individual needs.

However, staff could not always access statutory training or development.

The service had enough nursing and support staff to keep outpatients safe. We reviewed monthly OPD staff sickness rates from February 2025 to January 2026 across individual departments. The overall 12-month average sickness rate for all departments was 6.7%. This did not meet the trust target of 4.3%. Trust leads told us due to the small number of colleagues in some OPD teams, the sickness rate could seem higher. The department’s aging workforce and long-term conditions impacted their sickness rate. Leads had mitigations in place to manage operational gaps by cross-site working, bank staff use and part-time staff. This meant the number of cross-site nurses and CSWs matched those planned.

All OPD services monitored colleague sickness levels closely. Departmental managers, matrons and the human resources team reviewed sickness trends monthly. They maintained oversight through divisional workforce meetings. Leaders could request training if required around attendance management processes to better support staff.

The manager could adjust staffing levels daily according to patient needs. They used a staffing tool which gave them an overview of safe staffing levels. A dedicated staff member oversaw each clinic. The service had a process which adhered to the Developing Workforce Safeguards (NHS Improvement 2018) and National Quality Board guidance on Safer Staffing (2018). This used professional judgement and the Chief Nurse Panel’s analysis of quality indicators and review.

Leads undertook workforce planning in the eye clinic to increase staffing at peak clinic times. This was supported by ongoing training to ensure staff could work flexibly across subspecialties when required. Most OPD staff of all grades worked cross-site.

Certain specialties had trained up and developed staff to address their staffing shortfalls. For example, dermatology had two clinical nurse specialist who progressed to nurse consultants originally due to a lack of clinical staff. Doctor and consultant availability had since improved greatly.

Not all reception areas had a staff member present, some of these had self check-in machines instead. Staff said they were vigilant for patients who struggled using the machines.

OPD staff completed essential safety training (EST) annually. Most modules were e-learning online. Staff we asked had completed all their yearly EST and refresher training. During our assessment outpatients overall EST compliance was 94.5%. This narrowly missed the trust compliance target of 95%.

Staff told us their essential safety training was comprehensive and met the needs of patients and staff.

Staff received and completed training specific to their role, including bank staff. For example, eye clinic support staff had specialist training to use the Optos eyesight testing machine from their training coordinator. We noted the service’s improved position of OPD staff trained in children and young people (CYP) in areas where adult patients were also seen, such as gynaecology, surgery and general outpatients.

Line managers monitored all outpatient teams’ essential skills training compliance. They alerted staff when they needed to update their training. Human Resources provided regular updates to the team. Staff’s training compliance was a focus in performance review meetings. This supported oversight and ensured any gaps were addressed promptly.

Staff were competent and capable to fulfil their roles and responsibilities. We reviewed completed competency documents for all gynaecology clinic nursing staff. The division had standardised upskilling training for all lower band support staff.

Managers gave all new staff a full induction tailored to their role before they started working in the department. OPD leads gave all new starters a corporate induction booklet. Nursing and healthcare assistant staff also attended a local induction session. This gave them essential information about departmental procedures, key contacts, and department-specific expectations.

The service had a low vacancy and turnover rate. Staff vacancy rates across all Outpatients services for the 12 months from February 2025 to January 2026 averaged 7%. This matched the trust target rate.
Leads were training an in-house nurse colpo-scopist due to qualify in May 2026.

OPD departments staff turnover rates averaged 7.9% over the same 12-month period. The vacancies hotspots were areas with a predominantly B2 workforce. These staff would move to higher internal roles once they became available. We saw the most common reasons for staff leaving over the same 12-month period. They were retirement age and voluntary resignation – pay and reward related or work life balance.

Managers conducted return to work meetings after every period of staff absence. They ensured colleagues were well and considered any ongoing health issues for workplace adjustments or other supportive actions.

Managers could access extra nursing and support staff. They could also access a fully trained and embedded NHS bank team from the trust. Bank staff were offered regular shifts. They knew the consultants in clinic well and had gained good working relations.

OPD sometimes had to use bank staff to ensure safe staffing where there were vacancies or sickness. These were mostly used by three departments; gynaecology, ophthalmology and the library services. We reviewed bank usage for the six months from August 2025 to January 2026. Bank shifts were signed off by the relevant directorate general manager in advance of booking staff.

OPDs could include any additional, role-specific competency requirements within their bank staffing adverts. Divisional ADNs approved and aligned required competencies for bank staff for all essential and role-specific training required. Leads gave all bank-only staff a three-month window to ensure their competency was in line with the approved competencies.

Managers supported all staff to develop through yearly appraisals of their work. They supported staff’s learning and development needs. Managers reviewed staff on probation at their next appraisal or one to one.

However, despite the low overall vacancy rate, nursing leads could not always access extra nursing and support staff. Several clinics had ongoing or longer-term band 6 and 7 nursing staff shortages. For example, we were told dermatology was chronically understaffed. Shortages were often due to seasonal or longer-term sickness, maternity leave or staff not being able to source cover to attend essential safety training or CPD courses, such as the part two face-to-face Oliver McGowan LD and autism training full day. Some OPD clinic teams had barely any compliance in this module such as gynaecology. Some gynaecology clinic staff struggled to access training, as they could not be released or given protected hours to attend. The lack of staff was one department manager’s main concern.

A few OPD areas had higher than average vacancy rates above trust target. For example, B2 administration workforce in the appointments centre, reception and clinic preparation. Gynaecology OPD had higher than average vacancies due to difficulty recruiting to specialist nurse posts.

Some administrative staff told us cross-site working meant they were unsure where resuscitation and emergency equipment was located. This could make them feel disorientated and unsafe.

Trust leads took prompt action to address staff concerns about cross-site working. For example, they completed staff familiarisation with all working locations using a standardised format. This would be delivered and embedded during induction, to ensure staff visiting unfamiliar sites felt safe. Area and nursing managers referenced resuscitation trolley locations in daily safety huddles.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

However, we found the service did not meet control of substances hazardous to human health (COSHH) regulations onsite. Leads took prompt action to address these issues.

Infection prevention and control (IPC) data displayed on clinic waiting area dashboards showed most areas achieved 100% hand hygiene and OPD environmental audit compliance. We were sent hand hygiene compliance from November 2025 to January 2026 after our onsite assessment. This achieved 100% across all OPD areas. This divisional data could not be broken down to location specific information.

OPDs conducted several audits throughout the year in line with the trust’s IPC policy requirements. These were supported by additional audits and spot checks during outbreaks. Oversight of any issues around these audits was through the trust’s IPC strategic meeting with divisional reporting into the Patient Safety Quality Board (PSQB).

The OPD undertook a range of audits to provide assurance around IPC practices and environmental cleanliness. These included hand hygiene audits completed biweekly which focused on the World Health Organisation’s (WHO) Five Moments for Hand Hygiene and Bare Below the Elbow standards. The department had achieved 100% compliance for the past three months.

Nursing team members carried out front line ownership (FLO) audits biweekly. They gave immediate feedback at the time of the audit and discussed findings in patient safety huddles. The FLO audit’s IPC elements included antiseptic non-touch technique (ANTT), correct use of PPE, uniform policy and various assurances around safety, cleanliness and compliance of the general environment.

We received the department’s FLO audits from December 2025 after our onsite assessment. All wards or areas achieved the trust’s 90% target compliance or above. However, by January 2026 the community midwives - corridor one clinic’s compliance had reduced to 83.9%.

All OPD areas consistently achieved a 5‑star rating cleaning score in line with NHS cleaning audit standards. Hand hygiene and FLO audit outcomes were routinely discussed and results shared during departmental safety huddles.

OPD had an infection prevention quality improvement audit action plan from September 2025 which fed into the matron’s report. All actions were completed except for four ongoing. Two of these related to storeroom and dirty utility cleaning checklists, as these still needed printing. We found storage shortages leading to a lack of cleaning in some areas during our onsite assessment.

We reviewed all the trust’s IPC policies relevant to OPD practice. Staff could access a suite of infection prevention and control policies available on the trust intranet. OPD team members with IPC-related queries could access extra advice from the IPC service as required. The department used the National Infection Prevention Control Manual.

OPD had reported no infections assigned to any of their services in the last 12 months. Reportable infections included Methicillin-resistant Staphylococcus aureus (MRSA) and Methicillin-susceptible Staphylococcus aureus (MSSA) bloodstreams, Clostridioides difficile, E. coli bloodstream, Klebsiella spp bloodstream, and Pseudomonas spp bloodstream. No OPD incidents in recent years had required contact screening (such as measles or tuberculosis exposure). The trust’s IPC team would manage such incidents in accordance with their protocols.

The trust had policies in place to prevent and manage infectious diseases such as Methicillin-resistant Staphylococcus aureus (MRSA). This ensured outpatients, visitors and staff were not susceptible to infection both pre and post-operatively. MRSA is a type of bacteria resistant to many antibiotics. This makes it hard to treat.

Cleaning records were up to date and proved all areas were cleaned regularly. We found no gaps or errors in OPD deep clean records. Staff typically cleaned all areas daily. They used routine daily cleaning protocols, focusing on high-touch surfaces such as chairs, door handles, and reception counters.

Staff documented and monitored all cleaning activities to ensure compliance with healthcare hygiene standards.

Staff followed infection control principles including the use of protective personal equipment (PPE). We observed OPD nurses and support staff using suitable PPE for patient treatments. Most OPD clinic teams achieved 100% IPC training compliance.

Staff thoroughly cleaned furnishings and any equipment after patient contact. All decontamination of any devices used in OPD was completed onsite. For example, staff cleaned flexi-scopes in ENT every morning using ultraviolet sterilisation. They used three-step Tristel cleaning as a backup if needed.

We reviewed the trust’s latest in-date hand hygiene group policy. This outlined all necessary IPC steps staff and patients should follow, such as hand care, washing techniques and decontamination. OPD staff could contact an IPC lead nurse or a decontamination group for advice and guidance.

Cleaning materials and documents did not meet control of substances hazardous to human health (COSHH) regulations. These UK regulations are designed to protect workers from health risks associated with hazardous substances. They were not stored safely and securely in a locked cupboard. We saw no lockable COSHH cupboards anywhere in the dept. Some rooms were locked, but some digi-locks were left off the latch. This meant they were potentially accessible to people intent on harming themselves or others.

After our onsite assessment trust leads took prompt action to address COSHH issues by securing them safely. For example, all doors with locks were closed. Team leads reinforced to staff the need to ensure all locked doors are kept closed and locked through daily huddles and team meetings. Clinical area managers would spot check COSHH compliance to ensure practice was embedded.

The service ensured medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

Staff followed systems and processes to prescribe and administer medicines safely. The department’s most used medication was local anaesthetic. We saw nursing staff checked patient’s identification and allergy status before proceeding. Outpatient staff completed prescribing using the electronic patient record (EPR). This software had functionality to flag allergies and alert prescribers if they try to prescribe medicines to which the patient was allergic. Any interactions between concurrently prescribed new medications in OPD settings were immediately flagged for clinician review.

Staff reviewed each patient’s medicines regularly. OPD staff could access a lead pharmacist onsite.

Pharmacy technicians completed ambient temperature room and fridge checks for medicines throughout the department. Pharmacists completed fridge temperature recording audits to ensure safe storage of all OPD medications. They checked fridges daily with active temperature monitoring. Where fridge temperature deviations were outside of normal range, the clinic team were automatically alerted. The on-call pharmacist received alerts if the Acre Mill eye clinic fridge went out of range outside working hours. They moved stock if there was any sustained temperature deviation.

Staff completed medicine records accurately and kept them up to date. They checked patients had the correct medicines early in their pathway, and when they moved between services. Staff provided advice to patients and carers about their medicines.

OPD areas undertook medicines audits for assurance. We reviewed the latest annual peer medicines management audits in medical outpatients and ENT from September 2025. All areas were compliant for medical OP with no identified improvements. The ENT auditors advised one action to improve oxygen signage for their only non-compliant area.

Outpatient services followed trust policies related to medicines. Staff could access these on their intranet. The nurse in charge was responsible for medicines storage compliance. All medicines were stored within designated medicine cupboards. These were behind closed, digi-locked coded doors. Medicine cupboard keys were held separately in locked coded boxes in a separate location. Regular leadership walkarounds entailed checking medicines storage and ensuring digi-locked doors were closed.

Staff stored and managed all medicines and prescribing documents safely. All staff in OPD areas except one had completed medicines management training. Five bespoke role-specific training (RST) medicines modules included preparation, administration, storage and security. OPD managers and matrons reviewed RST compliance. This was also reviewed at directorate boards and divisional Performance Review Meetings (PRMs) as part of normal essential safety training reviews.

Staff learned from medicine-related errors and complaints. For example, leads received a complaint around the prescription renewal process for the nurse‑led gynaecology clinic which used a hormone therapy to treat cancers and women’s conditions. In response consultants implemented several improvements and process updates. This strengthened communication, prescribing safety, and governance oversight.

OPD had established a group to support the nurse-led hormone therapy clinic. Lead consultants were reviewing a related standard operating procedure (SOP) for this group. All clinical staff were sent a newsletter highlighting the new hormone therapy prescribing and administration process. These measures would ensure clarity, consistent practice, and timely hormone therapy prescribing aligned with guidelines. The SOP would also ensure appropriate documentation standards and effective management of general outpatients appointments.

Consultants could ask the pharmacist onsite to FP10 outpatient prescriptions. These were specific forms used by healthcare professionals to prescribe medications to patients in primary care.

Staff learned from medicine-related national patient safety alerts and incidents to improve practice. We reviewed four recent medication related incidents in the department from November 2025 to January 2026. Two of these occurred in trauma and orthopaedics. All had different categories and resulted in no harm.

However, only 88.9% of staff in gynaecology outpatients had completed medicines management training. This did not meet the trust target compliance of 95%. This meant we could not ensure all gynaecology staff could manage medicines safely and effectively.

We also found one Labcold fridge in the eye clinic area did not display the internal temperature.