Source · CQC inspection

Calderdale Royal Hospital

Provider Calderdale and Huddersfield NHS Foundation Trust Type NHS Healthcare Organisation Region Yorkshire & Humberside Last inspected 25 Aug 2023

Overall rating: Good  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Good
Well-led
Good

Earlier inspection findings

pre-2024 framework · 2 must-do 5 should-do

Must-do actions (2)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 2
Must do
Safe
The service must ensure all staff are up to date with all relevant training, such as training around the emergency evacuation of the birthing pools on the labour ward for midwifery staff and safeguarding level 3 training for all medical staff.
Regulation: Regulation 12(1)(2)(c)
⚠ Not all staff had completed mandatory training in line with trust targets, including safeguarding training for medical staff and birthing pool evacuation training for midwives on the labour ward.
Must-do action 2 of 2
Must do
Safe
The service must ensure there are at all times sufficient numbers of suitably qualified staff to meet the needs of women, birthing people and babies across the maternity service.
Regulation: Regulation 18(1)
⚠ Staffing levels did not always match planned numbers, leading to insufficient staff to care for women, birthing people, and babies, particularly in the maternity assessment centre and postnatal ward, which at times put safety at risk.

Should-do actions (5)

Recommended improvements to enhance service quality.

Should-do action 1 of 5
Should do
Safe
The service should ensure that they continue to monitor and drive improvement around compliance with documentation such as CTG fresh eyes and MEOWS.
Regulation: Regulation 12(2)(b).
Should-do action 2 of 5
Should do
Caring
The service should consider the location of the bereavement room as part of planned reconfiguration works in line with best practice guidance and the feedback and fundraising efforts of the local community.
Should-do action 3 of 5
Should do
Safe
The service should consider the regular reviews of ligature risk assessments across the service.
Should-do action 4 of 5
Should do
Well-led
The service should continue to improve on the appraisal rates for all staff.
Should-do action 5 of 5
Should do
Well-led
The service should continue to develop systems to ensure policies reflect current evidence-based best practice.

Location details

CQC ID: RWY02
Local authority: Calderdale
Region: Yorkshire & Humberside

Inspection report

Type: Location
Date: 25 August 2023
Rating: Good
Actions: 2 must-do 5 should-do
AI-extracted 2 Jun 2026