Source · CQC inspection
Huddersfield Royal Infirmary
Provider Calderdale and Huddersfield NHS Foundation Trust
Type NHS Healthcare Organisation
Region Yorkshire & Humberside
Last inspected 1 Jun 2026
Overall rating: Good View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Good
Well-led
Good
Current CQC assessment
Good
The service is performing well and meeting our expectations.
Ratings by service
Urgent and emergency services
Requires Improvement
Regulatory breaches & enforcement
Breaches identified (3)
Breach
Caring
We found breaches of regulations in relation to safe care and treatment, dignity and respect and staffing.
Breach
Overall
We also identified new breaches of regulation.
Breach
Overall
We found a continued breach of regulation in relation to the management of patients presenting with mental ill health.
Earlier inspection findings
Must-do actions (29)
Must-do action 1 of 29
Must do
Well-led
The trust must improve its financial performance to ensure services are sustainable in the future.
Must-do action 2 of 29
Must do
Safe
The trust must ensure they have robust systems for checking equipment and consumables and identifying and disposing of expired items.
Must-do action 3 of 29
Must do
Safe
The trust must ensure that systems and processes are in place and followed for the safe storage, security, recording and administration of medicines including controlled drugs.
Must-do action 4 of 29
Must do
Safe
The trust must ensure that they meet environmental audit targets for cleanliness or infection control.
Must-do action 5 of 29
Must do
Safe
The trust must ensure that deviations to appropriate fridge temperatures are escalated in line with internal policies.
Must-do action 6 of 29
Must do
Safe
The trust must ensure there is a suitable ligature room to accommodate patients presenting with mental ill-health.
Must-do action 7 of 29
Must do
Safe
The provider must remove ligature risks identified in key areas of the department.
Must-do action 8 of 29
Must do
Safe
The trust must ensure that systems and processes are in place and followed for the safe storage, security, recording and administration of medicines including controlled drugs.
Must-do action 9 of 29
Must do
Safe
The trust must ensure that deviations to appropriate fridge temperatures are escalated in line with internal policies.
Must-do action 10 of 29
Must do
Safe
The trust must ensure there is a suitable ligature room to accommodate patients presenting with mental ill-health.
Must-do action 11 of 29
Must do
Safe
The trust must remove ligature risks identified in key areas of the department.
Must-do action 12 of 29
Must do
Safe
The trust must ensure that they meet environmental audit targets for cleanliness or infection control.
Must-do action 13 of 29
Must do
Safe
The trust must ensure they have robust systems for checking equipment and consumables and identifying and disposing of expired items.
Must-do action 14 of 29
Must do
Safe
The trust must ensure medical staffing at Calderdale is in line with Guidelines for the Provision of Intensive Care Services 2015 (GPICS) standards.
Must-do action 15 of 29
Must do
Safe
The trust must ensure paper prescription charts are fully completed ensuring second signatures and batch numbers are recorded.
Must-do action 16 of 29
Must do
Safe
The trust must ensure all incidents are identified, reported and investigated, in a timely way.
Must-do action 17 of 29
Must do
Well-led
The trust must ensure that learning from incidents is shared, implemented, monitored and tested to embed lessons learned.
Must-do action 18 of 29
Must do
Safe
The trust must ensure at all times there are sufficient numbers of suitably skilled, qualified and experienced staff to reflect patients’ clinical needs.
Must-do action 19 of 29
Must do
Safe
The trust must ensure at all times there is sufficient staffing skills mix in line with best practice and national guidance to ensure clinical oversight and respond to patients’ clinical needs.
Must-do action 20 of 29
Must do
Effective
The trust must ensure staff complete induction training to enable them to carry out the duties they are employed to perform.
Must-do action 21 of 29
Must do
Safe
The trust must ensure staff complete mandatory training to enable them to carry out the duties they are employed to perform, including training in life support and in assessing and responding to patient’s risks.
Must-do action 22 of 29
Must do
Effective
The trust must ensure staff have the necessary competencies to enable them to carry out the duties they are employed to perform.
Must-do action 23 of 29
Must do
Safe
The trust must ensure patient record systems are in place to ensure staff have access to the information they need to respond to risks to patients and provide high quality care.
Must-do action 24 of 29
Must do
Safe
The trust must ensure risks to patients are assessed, monitored and mitigated.
Must-do action 25 of 29
Must do
Effective
The trust must ensure the nutrition and hydration needs of patients are met.
Must-do action 26 of 29
Must do
Responsive
The trust must ensure care is sufficiently personalised to take account of individual needs.
Must-do action 27 of 29
Must do
Well-led
The trust must ensure leadership and management processes are clear and roles and escalation processes are effective.
Must-do action 28 of 29
Must do
Well-led
The trust must ensure governance systems and processes enable oversight of operational risks and challenges.
Must-do action 29 of 29
Must do
Well-led
The trust must ensure systems are in place to measure the effectiveness and responsiveness of the service, and that relevant data is used to inform service-planning and evaluation.
Should-do actions (51)
Should-do action 1 of 51
Should do
Well-led
The trust should improve engagement and involvement with all staff groups with protected characteristics, such as staff with a disability or LGBT staff.
Should-do action 2 of 51
Should do
Well-led
The trust should improve the effectiveness of the Freedom to Speak up process.
Should-do action 3 of 51
Should do
Effective
The trust should develop processes to measure the outcomes of mental health patients in order to identify opportunities to improve care.
Should-do action 4 of 51
Should do
Well-led
The trust should strengthen on-going assurance and management oversight processes across the trust.
Should-do action 5 of 51
Should do
Safe
The trust should improve medicines management processes including monitoring of staff compliance and availability of pharmacy team support and oversight.
Should-do action 6 of 51
Should do
Effective
The trust should continue to strengthen staff knowledge and training in relation to mental capacity act and deprivation of liberty safeguards.
Should-do action 7 of 51
Should do
Responsive
The trust should ensure there are leaflets and resources available to patients whose first language is not English.
Should-do action 8 of 51
Should do
Safe
The trust should ensure that all staff complete mandatory training to meet their own targets for completion.
Should-do action 9 of 51
Should do
Safe
The trust should ensure they work to meet the Royal College of Emergency Medicine recommendation of 16 hours consultant presence in the department.
Should-do action 10 of 51
Should do
Safe
The trust should ensure that children are seen in an appropriate environment by staff that are suitably skilled, qualified and experienced.
Should-do action 11 of 51
Should do
Safe
The trust should ensure that all staff complete mandatory training to meet their own targets for completion.
Should-do action 12 of 51
Should do
Safe
The trust should ensure they work to meet the Royal College of Emergency Medicine recommendation of 16 hours consultant presence in the department.
Should-do action 13 of 51
Should do
Effective
The trust should continue to strengthen staff knowledge and training in relation to mental capacity act and deprivation of liberty safeguards.
Should-do action 14 of 51
Should do
Responsive
The trust should ensure there are leaflets and resources available to patients whose first language is not English.
Should-do action 15 of 51
Should do
Safe
The trust should ensure paper prescription charts are fully completed ensuring second signatures and batch numbers are recorded.
Should-do action 16 of 51
Should do
Safe
The trust should continue to work with staff to ensure sepsis screening is clearly recorded within the correct part of the electronic patient record.
Should-do action 17 of 51
Should do
Safe
The trust should encourage incident reporting within the unit to ensure all incidents including near misses are reported.
Should-do action 18 of 51
Should do
Safe
The trust should ensure staff are aware of safety performance within the unit and up to date information is displayed.
Should-do action 19 of 51
Should do
Effective
The trust should ensure data is collected for National Outreach Forum (NOF) and the achievement of West Yorkshire Critical Care Operational Delivery Network (WYCCODN) competencies and standards within the critical care outreach team.
Should-do action 20 of 51
Should do
Caring
The trust should use patient diaries in line with the guidelines for the provision of intensive care services (GPICS) recommendations.
Should-do action 21 of 51
Should do
Safe
The trust should ensure the system for checking emergency equipment and transfer equipment in the intensive care unit at Calderdale is clear, and should consider signing and dating the seal on the resuscitation trolley to provide assurance that the contents have not been tampered with between checks.
Should-do action 22 of 51
Should do
Safe
The trust should continue to work with staff to ensure sepsis screening is clearly recorded within the correct part of the electronic patient record.
Should-do action 23 of 51
Should do
Safe
The trust should encourage incident reporting within the unit to ensure all incidents including near misses are reported.
Should-do action 24 of 51
Should do
Safe
The trust should ensure staff are aware of safety performance within the unit and up to date information is displayed.
Should-do action 25 of 51
Should do
Effective
The trust should ensure data is collected for National Outreach Forum (NOF) and the achievement of West Yorkshire Critical Care Operational Delivery Network (WYCCODN) competencies and standards within the critical care outreach team.
Should-do action 26 of 51
Should do
Caring
The trust should use patient diaries in line with GPICS recommendations.
Should-do action 27 of 51
Should do
Safe
The trust should ensure all staff are up to date with mandatory training.
Should-do action 28 of 51
Should do
Responsive
The trust should respond to complaints in a timely manner and in line with their policy.
Should-do action 29 of 51
Should do
Safe
The trust should ensure that there is adequate staffing and accessible on-call cover at Huddersfield Birth Centre.
Should-do action 30 of 51
Should do
Safe
The trust should upgrade the attendance times of ambulances for priority one cases at Huddersfield birth centre from presenting a low risk to presenting a moderate risk on the maternity risk register.
Should-do action 31 of 51
Should do
Safe
The trust should continue to monitor transfer rates from Huddersfield Birth centre to the Calderdale site, and review why rates appear high compared to national averages.
Should-do action 32 of 51
Should do
Responsive
The trust should consider the necessity of closures of Huddersfield birth centre and their effect on the viability of the centre.
Should-do action 33 of 51
Should do
Safe
The trust should ensure all staff are up to date with mandatory training.
Should-do action 34 of 51
Should do
Responsive
The trust should respond to complaints in a timely manner and in line with their policy.
Should-do action 35 of 51
Should do
Safe
The trust should ensure all staff are up to date with safeguarding training; including safeguarding adults training.
Should-do action 36 of 51
Should do
Safe
The trust should consider the security arrangements in maternity areas to include the continued plans for electronic tags for babies. Additional guidance should be included in the abduction policy as regards vulnerable infants.
Should-do action 37 of 51
Should do
Safe
The trust should ensure that best practice staffing guidance as identified by the Royal College of Nursing (2013) is fully implemented.
Should-do action 38 of 51
Should do
Effective
The trust should ensure that the ‘Facing the Future’ standards are fully achieved.
Should-do action 39 of 51
Should do
Effective
The trust should ensure that children and young people’s mental health training sessions are available for staff.
Should-do action 40 of 51
Should do
Safe
The trust should ensure that arrangements are in place to monitor when band five staff are in charge of ward 18 without the advanced paediatric nurse practitioner (APNP) being present being present.
Should-do action 41 of 51
Should do
Safe
The trust should ensure that best practice staffing guidance as identified by the Royal College of Nursing (2013) is fully implemented.
Should-do action 42 of 51
Should do
Effective
The trust should ensure that the ‘Facing the Future’ standards are fully achieved.
Should-do action 43 of 51
Should do
Effective
The trust should ensure that children and young people’s mental health training sessions are available for staff.
Should-do action 44 of 51
Should do
Safe
The trust should ensure that all medical equipment in the neonatal unit is serviced as per contract identified.
Should-do action 45 of 51
Should do
Safe
The trust should ensure that the records trolley on the neonatal unit is locked.
Should-do action 46 of 51
Should do
Safe
The trust should ensure that all staff in the children’s outpatient department are aware of where to access a resuscitation trolley.
Should-do action 47 of 51
Should do
Effective
The trust should ensure patients’ capacity is considered in care planning.
Should-do action 48 of 51
Should do
Well-led
The trust should improve local audit systems, including documentation and environmental audits.
Should-do action 49 of 51
Should do
Effective
The trust should ensure patient outcomes are measured and monitored.
Should-do action 50 of 51
Should do
Responsive
The trust should ensure systems are in place to meet patients’ language support needs
Should-do action 51 of 51
Should do
Safe
The trust should ensure appropriate equipment is available to support staff in keeping patients safe, such as manual handling and falls prevention equipment.