Croydon University Hospital

Updated 22 February 2023

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at the Croydon University Hospital.

Croydon Health Services NHS trust provides integrated NHS services to care for people at Croydon University Hospital (CUH) and Purley War Memorial Hospital (PWMH). Services are provided to a population of approximately 383,000 people. Croydon University Hospital is based in South London. The population has a high level of deprivation compared to England average and has the youngest population of any London borough. Data shows that approximately a third of the population are aged under 25. Croydon Health Services is the main provider of maternity care for local women and undertakes approximately 3,500 births per year. The maternity service at the hospital comprises of a consultant led delivery suite, birthing pools, midwifery led unit, home birthing team, a dedicated operating theatre, recovery area, antenatal clinic, antenatal and postnatal wards, day assessment unit and a triage area.

We last carried out a comprehensive inspection of the maternity and gynaecology service in June 2015. The service was rated requires improvement for safe and good for effective, caring, responsive and well-led. The service was judged to be good overall. We previously inspected maternity jointly with the gynaecology service, so we cannot compare our new ratings directly with previous ratings.

We inspected the maternity service at Croydon University Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions. During our inspection, we visited all clinical areas in the service including labour ward, theatres, antenatal and postnatal wards, the birth centre, antenatal clinics and the day assessment unit. We spoke with 41 members of staff, including midwives, consultants, anaesthetists, senior managers, student midwives, matrons, ward co-ordinators, the risk and governance team, the safeguarding team and support staff. We reviewed five medical care records and five prescription charts. We reviewed a range of equipment including resuscitation equipment, grab bags, birthing pools, beds, mattresses, resuscitaires and cardiotocography (CTG) devices. We also reviewed the trust’s performance data and observed two multidisciplinary meetings and two handovers.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 11 February 2020

Our overall rating of this service stayed the same. We rated it as requires improvement because:

• Mandatory training in key skills for nursing and medical staff completion rates remained below the trust target of 90%.
• The directorate continued to be reliant on the use of bank and agency or locum staff to cover gaps in the staffing provision. Overall staffing levels appeared to have adverse impacts on continuity of care and factors such as recording medication administration.
• We remained unclear about how well the trust assured itself, through audits, that risk factors such as sepsis were being monitored per trust policy.
• Despite some improvement with nursing recruitment, the situation with allied health professionals (AHPs) has been allowed to deteriorate. The lack of after-hours therapist cover was unsustainable. Vacancy and sickness rates were high among AHPs.
• Medicines were not stored safely in the discharge lounge area.
• In some instances, record keeping was incomplete. For example, we found unfinished mouthcare charts on the Wandle wards. Some wards were using care record and prompt sheets that appeared to be locally published and had no document control. When we asked, there was confusion about who was responsible for the completing these records and who oversaw the processes. Emergency equipment records were, by comparison, very good.
• We found variation in the currency of resources available to staff, with several policies and guidelines out of date on the trust intranet.
• Patient outcomes for a number of indicators were worse than expected. For example, some services within the directorate had a higher than expected risk of re-admission and performance indicators for falls, dementia care and respiratory assessments were not always met.
• Appraisals were on a rolling programme with the expectation that all staff would have an appraisal at least once a year. In the last 12 months 58% of staff within the directorate had an appraisal, which was significantly lower than the trust target of 95%.
• There was not enough capacity as a result of the flow issues within the hospital to manage the medical patients in the right ward. Medical outliers were treated on surgical wards.
• While we saw recent improvements in the quality of data and the piloting of real-time process reports and alerts, this was only just beginning to impact on issues such as length of stay and flow of patients through the service.
• The service has yet to respond to extended length of stay and issues related to patient experience, such as those arising from the last patient survey.

However,

• Since our last inspection, equipment maintenance had improved. Staff told us they had sufficient equipment for their work
• We saw all grades of staff treat people with dignity, respect and kindness during their stay on the wards. Staff were seen to be considerate and empathetic towards patients. Most of the patients we spoke with were positive about the staff that provided their care and treatment.
• There was openness and transparency among all grades of staff and staff spoke positively about their line manager.

Updated 7 October 2015

Children’s services at Croydon University Hospital provided effective, caring and responsive support to premature babies, sick children and their families. Patient safety was assured though vigilant monitoring and responding to any deteriorating child.

Staff were required to complete safety related subjects but targets were not always met, particularly within the paediatric medical staff. There were some discrepancies in staffing levels of doctors and nurses due to vacancies, which were managed to ensure patient safety was not compromised.

There was an open and transparent approach to reporting and learning from incidents. Infection prevention and control measures were in place to minimise risks to those who used the service.

Effectiveness of services were geared to reducing emergency readmission rates and delivering the best treatment and care outcomes for children and young people, in accordance with best practice. A multidisciplinary team approach to patient care prevailed, and our observations and feedback from people using the services demonstrated that care was delivered in a kind, compassionate, respectful and friendly manner.

Responsiveness of the service was achieved through close working arrangements with community-based services, which ensured that children could expect to be cared for at home via community nursing services.

The service was well-led and staff spoke positively about providing high quality care that was aligned to the trust-wide vision of ensuring that patients received safe, clean and personal care. Whilst the overall care environment and ambiance of the Rupert Bear Ward and Special Care Baby Unit were tired and in need of refurbishment especially with regard to parent accommodation, the trust had acknowledged this was an area of concern and had developed action plans to improve facilities for babies and sick children.

Updated 11 February 2020

Our rating of this service improved. We rated it as good because:

• Our rating of the service had improved. We rated it as good because the trust had taken note of concerns raised about the critical care service at the previous inspection and made improvements in many areas such as governance, leadership practice and management of risk.
• Staff understood how to protect patients from abuse and the service worked collaboratively with other agencies to do so. Staff underwent training on how to recognise and report abuse and they knew how to apply it.
• Staff completed risk assessments for each patient swiftly and updated the assessments to minimise patient risk.
• There was an effective system in place to ensure policies, protocols and clinical pathways reflected national guidance. Managers checked to make sure staff followed guidance.
• Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients.
• The critical care performance was comparable with other similar units in the Intensive Care National Audit and Research Centre (ICNARC) audits for the period of 2018/19.
• The service made sure staff were competent for their roles. Patients were cared for by staff with the right qualifications, skills and knowledge to provide safe care. As at October 2019, 91% of staff have completed the post-registration critical care course, which was better than the Faculty of Intensive Care Medicine standard of a minimum of 50%.
• Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.
• The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patients subject to the Mental Health Act 1983.
• The critical care service was planned and delivered in a way that met the diverse needs of the local and surrounding population. Patients’ needs and preferences were considered and acted on to ensure services were delivered to meet those needs.
• Staff understood the impact of patients care, treatment or condition to their wellbeing and those close to them. Staff provided emotional support to patients to minimise their distress.
• The trust and service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
• There was a culture and focus of continuous learning, innovation and improvement in the service to improve patient outcome
• There were effective systems of governance that looked at quality and performance. Staff understood their roles around governance and there were structures for reposting and sharing information from the department to the division and board and down again.

However, we also found areas for improvement:

• Medicines were not always in date or within the use by date. However, staff followed systems and processes when safely prescribing, recording and storing medicines.
• The service provided mandatory training in key skills to all staff and made sure everyone completed it. However, we identified some areas where staff had not completed it, such as information governance and resuscitation trainings.
• There were systems and processes to control and prevent the spread of infection and the department was visibly clean, tidy and free of any odours. However, the service did not control infection risk well and staff did not always adhere to good infection control practice.
• There was no system in place to ensure equipment was regularly serviced. We found four pieces of equipment that were overdue for servicing.
   
• Although, the service met the ICS standard on the access to a follow-up clinic for patients discharged from the intensive care unit however there was lack of psychological and multi-disciplinary input at the follow-up clinic.
   
• Patients experienced delayed discharge from the service. In 2018/19, 8.7% of patients experienced a delayed discharge of over eight hours, which was worse than national average (4.5%) and similar unit (6.8%).

Updated 11 February 2020

We previously inspected diagnostic imaging jointly with outpatients so we cannot compare our new ratings directly with previous ratings. We rated it as requires improvement because :

Most staff were unable to show us training records demonstrating us they had received training to use the machines and carry out the procedures they were doing.

• Managers were aware of the lack of a comprehensive local induction for new staff members and were actively working on a new induction pack, however this meant new staff were not being inducted thoroughly and could miss important information as there was no record of what they had and hadn’t been trained to do.
• We were not assured all incidents were being reported and investigated thoroughly. Staff told us they did not always have the time to report all incidents and the department manager told us they were struggling to use the software.
• Department audits were not all formally logged and therefore their use and the validity of the data they produced was limited, as methodologies were not approved.
• The friends and family test was not broken down enough for the diagnostic imaging department to get their results. This meant that although the department was asking patients for their feedback managers were not receiving this information to act upon.
• We had concerns over the governance systems and how information and documentation was shared with staff within the department, including the robustness of the risk register. Many staff were not aware certain protocols and procedures were available to them to refer to. This meant they may have been unknowingly working outside of protocols they were not aware of.
• Clinical leaders did not have the time and resources to fully work through all the issues the department was facing and had been highlighted in reports written by their Radiation Protection Advisor (RPA) in 2018 and 2019. The reports both highlighted 15 of the same problems, demonstrating these had not been acted upon in 2018.
• Printed patient information was not available in languages other than English. With such a diverse multi-cultural population this could mean some patients were missing out on vital information as they were unable to read or understand English.

However:

• Staff carried out risk assessments and administered contrast safely in line with the patient group direction (PGD).
• Staff tailored their care to fit the patient’s needs and used a multidisciplinary approach when necessary.
• Many services were open seven days a week and superintendent radiographers in places which were not open seven days a week had the authority to open longer if they needed to. The impact of this was demonstrated in the fact that the department consistently achieved its six week wait time target and had consistently achieved this more often than the England average.

Updated 21 February 2018

Our overall rating of this service improved. We rated it as good because:

• The SPCT were competent, knowledgeable and responded to patients and their loved ones’ needs. The team had completed mandatory training.
• The SPCT worked as an integrated team with hospital and local hospice to promote continuity and consistency in patient care. The team also participated in local and national audits to share information.
• Staff knew what incidents to report and how to report them and managers were involved in investigating incidents and shared any lessons learned.
• The team held daily meetings, attended ward rounds and multidisciplinary team meetings across the hospital specialties, in order to provide knowledge, support and input into patients’ end of life care.
• Medicines were managed and prescribed appropriately and equipment was available to patients at the end of their life and equipment was well maintained.
• Palliative and end of life care was provided on many wards at the hospital and all staff were caring and committed to meeting patients’ needs.
• Palliative and end of life care services was provided by dedicated, caring and compassionate staff across the hospital. We observed care was planned and delivered in a way which took account of people’s wishes.

However:

• Whilst Do Not Attempt Resuscitation (DNACPR) were in place for patients and clearly identified on the electronic patient record (EPR), ward staff were not able to show us the completed forms. SPCT were able to access the forms easily.
• The consultant cover was .5 whole time equivalent (WTE) which is 1.5 WTE short of national guidelines. A business case had been submitted for additional consultants.
• Staff across the service understood how to protect patients from harm and abuse. However, they were not correctly assessing patients’ with regards to their capacity to make decisions about their care. Staff had training on safeguarding, the Mental Capacity Act, and Deprivation of Liberty Safeguards (DoLS), but we found areas of concern with regards to the Mental Capacity Act (2005) and the completion of DoLS application. The trust did not ensure that staff complied with its policy on Deprivation of Liberties Safeguards (DoLS).

Updated 22 February 2023

Updated 21 February 2018

Our rating of this service improved. We rated it as good because:

• Staff had completed mandatory training and they were supported with their professional development.
• There was good compliance with infection prevention and control practices.
• There were sufficient staff to care for patients and a matron had been appointed since our last inspection.
• Patients were positive about the care they received and told us they were involved in decisions about their care.
• Clinics were well organised and waiting times were within national standards for many conditions including cancer.
• A new dedicated cardiology department had been opened.

However:

• Not all staff were aware and had access to the risk registers.
• There was a backlog of some GP letters which the trust planned to clear by December 2017.
• Some staff at Purley War Memorial Hospital had some concerns about security.

Updated 21 February 2018

Our rating of this service improved. We rated it as good because:

• Since our last inspection the governance framework had greatly improved. A clear responsibility and accountability framework had been established. There was a systematic programme of clinical and internal audit, which was used to monitor quality and patient safety.
• Leaders had the skills, knowledge and experience to effectively manage teams within surgery services.
• There was a much improved and robust system for mortality and morbidity monitoring. There were good structures to govern mortality and morbidity and regular meetings took place to ensure regular oversight and scrutiny.
• Mandatory training rates had improved since our last inspection. There were detailed action plans in place with oversight to monitor core skills training.
• There was a better culture for the reporting and investigation of incidents. Staff received feedback on actions taken from serious incidents and there was shared learning in each surgical divisions clinical governance meetings. However, staff did not always receive feedback on low level incidents they had reported.
• Risk assessments were carried out regularly and in line with guidance. Staff understood their responsibilities and actions required in identifying patients at risk from deterioration, harm, and abuse.
• There were effective processes to ensure all relevant staff had the information they needed to provide care and treatment.
• The service routinely monitored and collected data to ensure safety and effectiveness. There was involvement in relevant local and national audits. Quality and safety was monitored and used to identify where improvement was needed, and actions were taken as a result, working together with external stakeholders.
• All policies and procedures were regularly reviewed and up to date.
• Staff provided care and treatment based on national guidance.
• Staff worked together as a team for the benefit of patients. Doctors, nurses, and other healthcare professionals supported each other to provide care and treated patients with compassion, treating them with dignity and respect.

However:

• There were still issues with old equipment and staff reported that the equipment replacement programme was running at a slow pace. Staff were still ‘firefighting’ with old equipment and this had an impact on their working environment.
• Although there was a theatre refurbishment project in place, staff told us the trust was not taking intermediate action in rectifying minor repairs.
• Much improvement had been made with clinical governance structures and leadership; however, consultants felt there was a widening gap in communication between themselves and the senior team. More work was required to establish good working relationships between the two teams.
• The surgical assessment unit (SAU) was still not being used for its intended purpose. We visited the SAU on two occasions during our inspection, and found it to be empty on both. Staff told us that the SAU was often used as an escalation area from the emergency department (ED) and to create additional bed capacity in the hospital.
• Some staff did not adhere to the trusts policy and guidance on the use of personal protective equipment (PPE), to prevent the spread of infection. We saw staff wearing jewellery not in line with trust policy and not all staff wore over gowns when leaving theatres to enter the main hospital. We saw personal staff bags were brought into the main theatres and anaesthetic rooms.
• Staff had noticed an increase in inpatients with mental health issues. This placed immense pressure on the demands of staff. Staff wanted better supportive systems in place to help them. Staff told us they required more specialist help and training to ease the pressures they faced.
• There had been minimal change to ensure patients did not become dehydrated before surgery. Nurses on admission told us anaesthetists did not have a standard approach with allowing patients to drink small amounts of clear fluids up to two hours before surgery. As a result, nursing staff said they often had to tackle patient complaints.

Updated 1 December 2021