Calderdale and Huddersfield NHS Foundation Trust

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

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has changed to good.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We observed that staff took a holistic approach to care, actively involving patients in assessing, planning and delivering their treatment. They carried out holistic comprehensive assessments using specialist tools where appropriate, including those for pain, frailty, mental health, nutrition, skin integrity and mobility.

Staff used the appropriate clinical tools and risk assessments dependent on the patient’s need to enable them to provide safe care. For example, NEWS 2, purpose T, (a pressure area care risk assessment) Rockwood score (a tool used to assess a patients fitness or frailty) , generalized anxiety disorder, complex geriatric assessment and a rapid bedside screening tool designed to detect delirium and moderate-to-severe cognitive impairment.

Staff told us risk assessments were completed either on the first visit or within the first 7 days of care. The trust used a computer software program that enabled them to monitor the completion of risk assessments and care plans. In addition, managers completed audits to provide assurance on the completion of risk assessments which included the quality.

The community health services for adults completed a record keeping audit every 3 months, where a sample of 5 patients per team were audited on a rolling programme. Information submitted for quarter 3 (October to December 2025) showed that 95% of records had been completed within 24 hours and had patient involvement in all aspects of care, 80% of relevant risk assessments were completed within 7 days (within 24 hours for palliative care patients). Where results were below 79% an action plan was agreed by the patient quality and safety board and shared throughout the service. Examples were ensuring patient demographics, next of kin were recorded and not using abbreviations.

The staff used the same computer software as most of the local GP practices; this enabled them to promptly flag any issues with GPs and other health professionals.

The district nurses had access to specialist advice and support where they encountered complex cases, such as tissue viability, respiratory, bladder and bowel, Parkinson’s disease, diabetes and palliative care nurses.

Where we observed patient care, patients told us they were involved in the assessment of their needs and felt staff provided information when their care and treatment commenced. This included information and advice about their health, care and other available support.

Staff at all levels we spoke with were competent and knowledgeable. They were proactively supported to acquire new skills, use their transferable skills and share best practice. Staff were required to complete competency assessments before undertaking tasks independently and additional training was tailored to meet individual needs.

The trust carried out regular audits of patients’ records. Results were shared with the team leaders and at patient safety and quality board, and any issues were followed up. In addition, the district nurse team leaders explained how they would provide staff with support and review their competency.

Staff told us they felt fully supported and supervised and team leaders described an open-door policy, daily handovers, accompanying staff on visits or following staff into visits to check compliance.

Our observations of staff providing care and a review of a sample of patient records demonstrated that staff assessed patients’ needs and delivered care in line with clinical standards and evidence-based guidance, supported by pathways and appropriate tools. Staff followed up-to-date policies to plan and deliver high quality care in line with national guidance.

Compliance with national guidance was reviewed at the patient safety and quality board.

District nurses demonstrated effective multidisciplinary and integrated working with tissue viability, diabetic services, and other specialist teams. They described clear information sharing processes that supported continuity of care. A daily handover meeting was observed where the district nursing team shared patient information.

Leaders described good relationships with the hospital wards and attended regular meetings throughout the day to monitor patient discharge.

The community health services for adults offered hospital at home, which helped prevent avoidable admission to hospital, supported early discharge out of hospital, and increased the overall bed-base available for acute care. In addition, Quest for quality in care homes, a multidisciplinary team that worked with providers and focused on reducing falls and hospital admissions through specialist support. Staff told us they had positive relationships with external health and social care stakeholders. They worked effectively with inpatient services, social care and primary care clinicians to deliver services.

Staff supported people to manage their health and wellbeing. They focused on prevention and early intervention to help reduce future care needs. Staff identified health risks such as end-of-life needs, carer responsibilities and supported national health priorities, including smoking cessation and obesity reduction.

A cardiac rehabilitation nursing service was in place, this team led healthy eating discussions, operated a healthy eating group and had specialist scales that gave fat and water reading to support patients in their weight loss.

The community health service for adults offered quest for quality in care homes, a multidisciplinary team service. The service provided advice and support to staff in care homes on the prevention and proactive management of the needs of older people. This aimed to reduced hospital admissions, enabling patients to remain in familiar surroundings.

The service had a programme of quality improvement activity, teams used data to understand and improve services. Managers and staff carried out a comprehensive programme of regular audits to check compliance and make improvements to support the delivery of care.

Individual clinicians led on audits which included infection and prevention control, environment, and patient records.

Managers told us they monitored team performance through observation, team and handover meetings, patient record audits and follow up visits to patients.

The leaders told us that during 2025/2026, the community services participated in 100% (7/7) of the mandated national clinical audit projects. These included diabetes footcare, cardiac and pulmonary rehabilitation, adult asthma, risk assessments, record keeping and intravenous fluids on virtual wards. An additional national project to evaluate the care offered to patients and their relatives from specialist palliative care services was also undertaken. Where appropriate the leaders had implemented an action plan.

We observed that staff supported patients to make informed decisions about their care and treatment. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. 94.5% of nursing directorate staff had completed deprivation of liberty safeguard level 3 training as of January 2026.

Where mental capacity assessments and best interest decisions had been completed, they were decision specific and signed by the relevant parties. When patients could not give consent, staff took into account their wishes, culture and traditions, as well as the views of any family or carers, where appropriate.