Calderdale Royal Hospital

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• 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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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.

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.

OPD staff understood but could not always articulate the trust’s clear vision, values and behaviours. The trust had four behaviours to underpin its vision. These helped staff deliver compassionate care.

We saw staff embodied the trust’s culture of care by putting people first and working together to get results. The service itself had a pledge to patients based around the six C’s; courage, care, communication, commitment, competence and compassion.

Some senior and nursing leads could articulate the vision for their service. For example, in gynaecology leads planned to develop a gynaecology assessment unit to same day emergency care (SDEC) pathway. This would improve their outpatient experience.

In cardiology the department manager outlined the building of a new cardiology laboratory to treat outpatients with more complex cases. The general OPD involved managers and staff in making their service more patient-led. For example, clinicians would see people at their preferred site.

The OPD manager understood their strategic priorities and how they related to wider hospital services. They shared some examples of service improvements and project development.

However, staff were largely unaware of any clear timeline for planned building or service expansion works (beyond the new car park). One manager reported that staff were not involved or consulted on changes and were only informed once decisions had been made.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The OPD manager clearly demonstrated oversight, dedication and focus of all clinical and non-clinical governance processes, arrangements and issues within their department. Staff told us leaders and especially their manager were highly visible. They would always make themselves available when required.

Senior trust and service leads were working to improve outpatient processes and follow up arrangements.

The manager was well supported and maintained good cross-site relations with the divisional and senior leadership teams.

The OPD manager attended all relevant meetings. This included a short weekly patient safety incident response group (PSIRG) after the huddle to discuss any issues. For example, if complex patients were suitable to attend clinics.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us the service had a positive, friendly and inclusive culture. All OPD staff we spoke were positive about working for the hospital and felt respected, appreciated and well supported by managers and teams to raise any suggestions or concerns.

The OPD adhered to the trust’s Just Culture approach. This ensured investigations focused on understanding systems and identifying opportunities for improvement, rather than blaming individuals. Levels of investigation were matched to severity and risk, guided by the trust’s Patient Safety Incident Response Framework and Plan. This approach supported open reporting, encouraged staff engagement, and ensured learning responses were proportionate, insightful, and aimed at preventing recurrence.

Staff knew how and where to contact the hospital’s freedom to speak up guardians (FTSUG). They were visible in the main outpatients reception area.

They could access support from occupational health and an external counselling service if needed. Posters signposted staff to wellbeing organisations and resources.

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.

Senior leads and managers reminded staff to complete the yearly staff survey. Leads shared survey results with the relevant teams for review and response. They set a divisional action plan yearly and captured actions for any overall themes identified. Divisional leads had assigned owners and strategic themes to help them monitor the progress of all actions. Directorates also set their own local action plans. Some specialties such as endoscopy had devised their own service-specific staff survey. We also saw plans and engagement activities from paediatric leads in response to staff survey results.

Service leads had taken actions in response to the 2024 results. They tackled areas where they saw the biggest staff decline in engagement compared to the previous year. We saw the OPD staff survey feedback overview for 2024. This divisional data was not broken down to location specific information. This had a reduced engagement score compared to 2023. As a result, leads’ area of focus was on setting up engagement activities. We heard this was a key strength across outpatient areas. Leads monitored the survey’s people metrics since these results. These had remained consistently high.

Directorate Performance Review Meetings (PRMs) included staff engagement and survey as a discussion topic. Teams provided updates on actions undertaken and planned. Leads discussed survey results and actions yearly in a range of trust forums and reported on their progress. We saw examples taken from Directorate PRMs and the Trust Workforce Committee. Leads shared other communication approaches such as ‘You Said, We did’ posters within OPD areas.

The directorate had a workforce strategy. This included diverse and inclusive workforce objectives, as well as local employment, career and voluntary opportunities. Leads monitored and RAG rated this one-year strategy’s workforce elements. Elements were also informed by the staff survey’s output. A culture of care and wellbeing open door policy with access to a human resources representative formed part of the best place of work commitment.

Staff could submit ideas and nominate colleagues for star of the month awards. They were given the opportunity to have a voice through ‘you said, we did’. We saw the general OPD team had been nominated for a trust award.

Many staff in the department praised the senior staff’s responsiveness, accessible staff wellbeing facilities, social events and the hospital’s open culture.

The trust had an equality and diversity team staff could contact.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Nursing and clinical staff would apply relevant clinical codes and outcomes onto the EPR system. This data was reported and captured through clinical dashboards for review by hospital governance leads.

OPD managers and clinical staff used a system for reporting clinical governance issues. Leads reviewed reports to inform governance discussions. Staff attended weekly patient safety meetings to promptly cover any issues.

Managers had a project underway to centralise all OPD appointment bookings through a hub and spoke model. They told us this would improve governance and oversight. They planned to recruit the newly created role of hub operations lead in preparing to launch the pilot by April 2026. This work sought to better capture outpatient’s person-centred needs and requirements using business intelligence tools.

OPD leads had clinical representation at the medical advisory committee. The clinical director for orthopaedics attended and fed back any discussions with relevant staff.

Leads proactively reviewed governance arrangements which reflected best practice. OPD related governance structures included monthly quality and safety meetings. All procedures we reviewed were signed and completed within date during our assessment.

During industrial action, most trust cancellations affected OPD follow up appointments contributing to a backlog. Leads had noted follow up appointments were not prioritised in national funding or performance metrics. This made it difficult to address their growing backlog. Divisional operatives had work underway to manage this.

Service-specific risks were frequently reviewed and escalated appropriately. Relevant OPD related risks could be escalated up to the executive board through the audit and risk committee.

Leads and managers were aware of key areas of risk which affected their services. They had actions in place to address and mitigate them. We reviewed trust-wide and divisional risk registers. The highest scored risk across all OPD specialties was ENT waiting times for patients. This scored 16 out of a possible 25. Actions were in place, such as a healthcare contractor providing extra weekend capacity and a task and finish group to identify solutions and improvements. This divisional data could not be broken down to location specific information.

OPD’s second and third highest corporate risks were in children’s services and therapy. One related to limited paediatrics administrative capacity resulting in delays delivering timely correspondence. The other was financial and related to CYP not receiving timely and adequate clinical assessment for education, health and care plans (EHCPs). Both were scored 15 out of 25. Actions were in place to mitigate this and all risks.

All OPD investigations were governed through a clear divisional assurance structure. Learning responses are first overseen at the Divisional Patient Safety Event Panels, where themes and actions are reviewed. Investigation outcomes and learning are then escalated to the Divisional Patient Safety Quality Board (PSQB) for further oversight and assurance. A key learning and actions summary was incorporated into the Quality Report. This was formally submitted to the Trust Quality Committee. In addition, the overarching Trust Patient Safety Panel oversaw and assured the quality and approval of all PSIIs.

The patient safety incident response framework (PSIRF) process facilitated OPD’s learning from clinical incidents which identified good practice. The department’s PSIRF response process was outlined in the trust’s PSIRF plan and policy. This used a system‑based learning method including SWARM huddles, PSIIs, after action reviews, multidisciplinary team or case note reviews and thematic analysis.

We reviewed governance structures covering all outpatient areas. The gynecology department reported monthly to the gynecology, Yorkshire fertility, sexual health department management team meeting. Key issues and discussions were escalated up through directorate and divisional governance meetings.

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.

The division actively fostered cross-site team development through engaging and inclusive activities. These helped strengthened collaboration, wellbeing, and shared culture across departments.

The main OPD had a well-used league of friends tea bar. This gained very positive feedback from patients and families in waiting areas. The bar raised £100,000 of trust funds in the year before our assessment.

We were sent evidence of the department’s outreach work to engage minority groups and those less heard. For example, leads had taken part in carer’s week 2025 and shared their insights with staff.

Leads held regular governance meetings with partner providers, stakeholders and other regional trusts. For example, OPD managers met with NHS ambulance service operations managers bi-monthly. They had open, honest discussions about any challenges or issues.

Gynaecology outpatients worked in partnership with their community diagnostic hubs.

Leads encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

However, staff could not always source shift cover to focus on continuous learning, innovation and improvement across the organisation and local system. This was due to seasonal or longer-term sickness of nursing staff impacting colleagues ability to gain shift cover for CPD and wider opportunities.

The service had improved continuity of care and outcomes for outpatients with dementia who had a fractured neck of femur. Leads had moved one resident doctor from OPD onto each hospital ward. This meant they had closer relations with this cohort once they became inpatients.

The service had research projects underway in orthopaedics, surgery and physiotherapy. One such study compared different approaches to physiotherapy after shoulder surgery. The orthopaedics department had a clinical support worker research champion and fracture clinic had allied health professional research nurses.

We were sent examples of service improvement work for OPD bookings. The new hub model supported timely scheduling, reduced waiting times, provided consistent communication, and improved outpatient experience. For colleagues, the programme introduced clearer career pathways, improved support, defined expectations, and recognised specialist skills in booking teams.

Other service improvement examples included a new tiered workforce model (Bands 2–5). This had created clear roles, training pathways, apprenticeships and career development opportunities. This improved staff capability and wellbeing.

OPD had improved digital integration, including EPR, key performance plus dashboards, and the digital patient portal. These integrations enabled real‑time visibility, intelligent scheduling, and reduced manual workarounds.

OPD service improvements were underway in gynaecology, ophthalmology, paediatrics and integrated medical services.

However, we found or heard about no examples of staff-led quality improvement projects, training or initiatives. Managers and nursing staff said they lacked time to complete any in their teams.

OPD had some environmental and sustainability initiatives. For example, the endoscopy service had four green staff champions. They encouraged other staff to sign a pledge, travel smart and reduce carbon emissions.