All inspections: Croydon University Hospital

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.

We carried out an unannounced focused inspection of the emergency department (ED) at Croydon University Hospital on 21 and 22 September 2021.

We carried out this inspection as a follow up to concerns about the quality and safety of the service raised in previous inspections, including the care of patients with mental health problems. The emergency department (ED) had been issued with requirement notices in February 2020 and imposed conditions following a focused inspection to the care of mental health patients in December 2020. At our last comprehensive inspection (February 2020) we rated the trust as requires improvement overall and the urgent and emergency service as requires improvement.).

As this was a focused inspection, we did not inspect all key questions. Our priority was to identify if the service was safe, responsive and well led and monitor progress since the previous inspection.

We found improvements had been made in the care of patients with mental health problems. However, during our inspection we identified breaches of regulation 12; safe care, and of regulation 17; governance. After the inspection we told the trust it must make improvements issuing the provider with a requirement notice.

Our rating of services stayed the same. We rated them as requires improvement because:

Infection and prevention control was not assured all the time within the ED. Overcrowding in the paediatric waiting area and the waiting area reserved for possible adult COVID positive patients represented risks of infection prevention control to patients.
There was overcrowding in the paediatric ED and we were not assured escalation and social distancing policies were being enforced.
Resuscitation equipment was not checked daily.
The ED had nursing staffing shortages which were significant in the paediatric ED.
Triaging in the paediatric ED did not meet the recommended 15 minute clinical standard.
The service had a significant backlog of reported incidents to review and close.
People could not always access the service when they needed it. Waiting times for patients to be admitted, transferred or discharged were not in line with good practice.
Staff voiced concerns about the workload becoming unmanageable with the continuing increase of attendances and staff shortages in their establishment.
We were not assured the risk register represented all risks to the department.

However:

The service had updated their physiological scoring measurement tool in line with clinical guidance.
Patients had access to a psychiatric liaison nurses 24 hours a day. Staff told us although the team were increasingly busy, they were responsive and would see patients within one hour of initial referral.
The service had improved their risk assessment of patients with mental health concerns. Notes from care plans by psychiatric liaison nurses were readily available and environment risk assessments and actions completed.
There was a stable leadership team in place
Staff in the adult ED told us they felt respected, supported and valued by service leaders. They were focused on the needs of patients receiving care.
The service had an auditing programme in place to support performance improvement, identifying good practice and supporting service development.
Governance processes had improved since our last inspection.
The trust addressed the concerns raised in our focused inspection in December 2020 by conducting and external review of care of patients with mental health problems and were taking steps to implement the recommended actions.

How we carried out the inspection

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.

During our inspection we spoke with 12 registered nurses, seven medical staff, one health care assistants (HCA) and three other staff including a receptionist. During the inspection we also spoke with the urgent and emergency service head of nursing and paediatric head of nursing and the clinical lead for the department.

We reviewed 17 adult patient records and four paediatric patient records. Of the 17 adult patient records, seven were for patients who attended the ED with mental health concerns.

Croydon Health Services NHS trust was formed in July 2010 with the integration of Mayday Healthcare NHS trust with Croydon Community Health Services. The trust provides integrated NHS services to care for people at home, in schools, and health clinics across the borough as well as at Croydon University Hospital (CUH) and Purley War Memorial Hospital (PWMH).

The trust has 449 inpatient beds, 20 inpatient wards and 37 day case beds. The emergency department is at Croydon University Hospital. Purley War Memorial Hospital does not have any inpatient beds and services provided include phlebotomy and outpatient clinics.

The trust employs more than 3,800 staff and has a dedicated team of 420 volunteers.

We last inspected the trust in October 2019 and it was rated requires improvement overall.

Our rating of services remained the same. We rated them as requires improvement because:

We found concerns about the quality and safety of care in three of the four services we inspected.
Systems to monitor the quality and safety of care were not embedded in some of the services we inspected
Actions to minimise risks to patients had not always been recognised and taken and in some instances the hospital had not always taken action swiftly enough. Risks in some services were not always reviewed with actions to mitigate them.
We found systems for reporting and learning incidents were not always effective.
Patient records were not always accurate and up to date.
Staff were not always using best practice guidance and monitoring the effectiveness of care and treatment.
The uptake of appraisals was variable in the services we inspected.
In the emergency department patients could not always access the service when they needed it and the trust was not always meeting the national standards for waiting times.
Feedback from patients via the NHS Inpatient survey and Friends and Family test showed a downward trend in responses, experience and if they would recommend the trust.

However:

We found the trust had made improvements in critical care. Improvements included more effective leadership and awareness among staff of the need to protect patient’s privacy and dignity.
Patients and relatives we spoke with were happy with the care they received, they told us staff treated them with kindness and compassion.
Staff told us their immediate line managers were visible and approachable, and they felt valued and supported.
Waiting times for diagnostics were better than the England average.

Croydon University Hospital is operated by Croydon Health Services NHS Trust. We carried out a focused inspection on 5th and 6th August in response to concerns we received from patients and relatives about the nursing care provided in medical and surgical services and the results of the 2018 NHS inpatient survey. Although there was a low response rate to the survey, the trust was identified as ‘much worse than expected’ when assessing overall experiences for all patients. The concerns from patients and relatives were that nursing staff did not always treat patients with dignity and provide support with their personal needs.

Our inspection began on the evening, 5 August, and we went back the following afternoon. It was unannounced (staff did not know we were coming) to enable us to observe routine activity. As we carried out a focused inspection, which did not include all key lines of enquiry (KLOEs), we have not rated the services or hospital as a result of this inspection.

During the inspection we visited medical wards; Heathfield 1 ward, Purley 1, acute care of elderly (ACE) ward, Wandle 1 and one surgical ward Fairfield 1 and cardiac day care which was being used as an escalation ward overnight to increase the capacity of the hospital.

We spoke with 21 members of staff including nurses, allied health professionals and ward support staff. We reviewed healthcare records and spoke to 21 patients and relatives.

Before and after the inspection visit, we reviewed information that we held about these services and information requested from the trust.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we rate

As this inspection focused on areas of concern and we have not rated the services we inspected or the hospital.

Our key findings were as follows:

Patients provided differing accounts of how caring staff were; some very positive about their experience while others raised concerns about the attitude of a few nursing staff.

Some patients told us they were aware of how busy ward staff were and this discouraged them from using their call bells unless absolutely necessary.

Many staff we spoke with said they felt there was a high ratio of patients to staff and they were not always able to provide the standard of care for patients they aimed to.

There was a shortage of permanent nursing staff and healthcare assistants on the wards we visited.

The hospital had experienced high bed capacity and relied on the use of escalation areas. These were sometimes opened at short notice, staffed by bank and agency nurses and at times impacted on patients who were booked to have planned procedures.

The hospital’s Friends and Family Test (FFT) showed a significant reduction in the number of patients who would recommend the hospital to loved ones in the past year.

We found an inconsistent approach to the care of patients living with dementia with at times delays between the request for a capacity review and it being carried out along with a lack of clarity about the care plan for a few patients.

Some staff felt that communication from senior managers could be improved and they were not aware of the hospital staff forums.

However we also found:

The planned nurse and health care assistant (HCA) staffing levels on wards were generally being achieved through the use of bank and agency staff.

Some patients felt they had received good care and that the nurses were friendly and caring.

The majority of records we reviewed were generally complete and up to date.

Staff knew the key signs that a patient may be lacking capacity and how and when to request a review of a patient’s capacity to make decisions.

The hospital had some resources to support patients living with dementia and assist staff with their care.

Staff were positive about the teams they worked with and their immediate line managers.

Following this inspection, we told the provider that it must and should make improvements to help the service improve. Details are at the end of the report.

Name of signatory

Nigel Acheson Deputy Chief Inspector of Hospitals (London and South England)

Our rating of services stayed the same. We rated it them as requires improvement because:

In medical care, there were large number of outliers and patients being moved at night.
The service was reliant on the use of bank and agency staff to cover gaps in the staffing provision; however the trust could not be assured agency and bank staff were being inducted onto wards appropriately or when they commenced on a new ward.
The trusts own internal audit data for hand hygiene within the service identified compliance was variable across the medical wards. Compliance varied from between 100% and 56%.
Maintenance on the medical care wards and equipment was not always undertaken in a timely way. We found that repairs to windows on one ward had been waiting for six months.
Wards had little public health information on the national priorities to improve the population’s health on smoking cessation, obesity, drug and alcohol dependency, dementia and cancer.
Medical outliers were treated on surgical wards. The trust reported that over the last 12 months for the period April 2017 to March 2018 the number was 9,646.

However:

There was a clear leadership structure within the medical care core service.
There was a culture of honesty, openness and transparency within the service. We saw evidence of senior staff carrying out duty of candour responsibilities which detailed the involvement and support of patients or relatives in serious incident reports.
We saw evidence of secure record keeping within the medical care core service.
Serious incidents were discussed as part of the monthly patient safety and mortality committee meetings and the integrated adult care governance. SIs were investigated, had an action plan and lesson learnt identified.
The trust had introduced a ‘10 steps’ meal distribution process to ensure that patient received their correct diet. Protected meal time were being strictly observed. Nursing staff were on ward so they could support and monitor patients who required assistance. The nurse in charge checked to ensure that patients were being given the right food which was checked against menu sheets and the nutrition boards.
The results of recent published audits showed the service to be performing in line with national averages. In some cases where performance fell below the England average there was an improvement seen since the previous audit.
There was effective multidisciplinary working within medical care.

Croydon Health Services NHS Trust provides local services, primarily for people living in and around Croydon from the two locations, Croydon University Hospital and Purley War Memorial Hospital. The Purley Memorial hospital provides outpatient and diagnostic services only. Croydon University Hospital provides acute services to a population of 383,000.The trust also runs15 community clinics across the area.

The trust employs approximately 3,640 staff and has a team of 300 volunteers supporting the services.

We carried out an announced inspection visit to the hospital services and community clinics between 16 and 19 June 2015. We also undertook an unannounced visit to the hospital and community clinics on 23 June 2015.

Overall, this hospital requires improvements.

Our key findings were as follows:

Safe

The trust had reported fewer incidents than other trusts of its size and some incidents may not have been reported.
Staff were encouraged and supported to report incidents when they occurred. However, staff working in operating theatres did not always complete incident reports.
Incidents were not always recorded and categorised as serious until after a complaint had been received.
Investigations in the majority of instances had been undertaken in an open and transparent manner. Review processes in the surgical division did not always include adequate examination of the root causes of the incident, and did not explain the consequences in a way that relatives could understand.
Patients were informed when a serious incident had happened and were updated on the progress of the investigation.
The service arrangements in the Emergency Department (ED) did not always enhance patient safety. Patients who did not arrive by ambulance were not always clinically assessed as soon as they arrived. Some ED patients were sent in error to the urgent care centre following an initial assessment by staff running the adjacent urgent care centre.
Although it had been difficult to recruit and retain nursing staff, there were adequate arrangements to ensure safe nursing staff levels.
There were sufficient medical staff to provide safe treatment and care to patients, although the availability of surgical cover on Sundays did not support the delivery of a trauma service.
There were arrangements to minimise risks of infections to patients, the public and staff. However, equipment used by patients had not always been cleaned to the required standards in the Emergency Department. The environment in Cardiology was not sufficiently clean or well maintained. Operating theatres were in a poor state of repair.
Elective orthopaedic cases were nursed on the mixed surgical speciality wards, which did not reflect recommendations for delivery of safe surgical services by the Royal College of Surgeons.
Arrangements for medicines optimisation ensured the safe and effective use of medicines for the best possible patient outcomes. However, medicine fridge temperature checks were not done regularly in some surgical areas.
Patient risk assessments were undertaken and where patients' conditions deteriorated, their needs were responded to by appropriately skilled staff.
Staff had access to safeguarding information and had a good awareness of this area of patient safety; however, safeguarding of vulnerable adult training was not always up to date across the various departments.
Staff compliance with mandatory patient safety related training was often below target levels.
Equipment used for surgery was sometimes inadequate or unavailable.

Effective

Where possible, staff followed best practice standards and professional guidance for clinical practice.
There was no trauma service on a Sunday, which was not in line with Fractured Neck of Femur (NOF) guidelines.
There was a collaborative and multidisciplinary approach to the delivery of patient treatment and care from clinical and allied healthcare professionals. The exchange of patient information was not optimised on surgical wards, where consultant ward rounds often took place without a nurse present.
Access to services and clinical experts outside normal working hours in the main supported the effective delivery of care.
Patient outcomes were generally in line with or better than the national average except for emergency trauma and orthopaedic surgery. Readmissions following emergency trauma and orthopaedic surgery were worse than expected.
Staff had access to training and opportunities to gain competencies related to their area of work.
The assessment of patients' pain was carried out and the majority of patients reported having timely pain relief.
The individual nutritional needs of patients in ward areas and the Emergency Department were considered and acted upon. However, there was no standardised protocol to ensure patients did not become unnecessarily dehydrated before surgery.
Staff sought consent from patients before undertaking treatment and care. Consent took into account the best interests of individuals who were not able to make informed decisions for themselves. However, in medical services there was a lack of assurance that capacity assessments were always being carried out when needed and consent was not always recorded in medical notes.
There was no formal arrangement to access anaesthetic review of surgical patients at pre-assessment. Procedures were sometimes cancelled as a result of patients not having been reviewed by an anaesthetist.
There was no agreed process for radiological investigations required by the day surgery unit.

Caring

Staff provided physical and emotional care to patients in a kind, considerate and compassionate manner. Patients were treated with dignity and respect and were supported with their individual needs. Those people who were important to the patient were involved in their care where wished.
The needs of patients living with dementia or having learning disabilities were considered and addressed.
Multidisciplinary meetings included discussion of the patient’s choice and relatives' involvement when planning discharge and follow-up care arrangements.
Patients and their families felt involved and listened to but medical patients said there was a lack of information related to their treatment. Staff respected decisions and choices, and were supportive of varying cultures, backgrounds and faiths.

Responsive

Services had been planned and arranged to meet the needs of the local population.
Some patients spent too long in the Emergency Department before being admitted to a ward.
Elderly care pathways ensured that elderly patients were assessed and supported with all their medical and social needs.
The acute liaison nurse for patients with a learning disability worked closely with staff to improve the patient experience and the effectiveness of treatment.
Theatres were under used and scheduling of operations was not planned to take account of demands on the day surgery unit or on the Intensive Care Unit.
Some surgical procedures were cancelled on the day as a result of a lack of equipment availability.
The length of time from referral to treatment for surgery was now generally in line with, or better than, the national average.
Care pathways for surgical patients were enhanced by multidisciplinary working with specialist nurses and links with the trust community health services.
Volunteers worked closely with staff to ensure people's needs were responded to.
Discharge arrangements were not always efficient, with patients waiting too long in the discharge lounge and waiting too long for their prescriptions. There were blockages in the discharge of surgical patients due to lack of rehabilitation beds in the community.
Staff understood the complaints reporting and investigation process. Work to improve the complaints management process had taken place but there remained some delays in updating people on the progress of investigations.

Well led

The majority of clinical areas were well led, with strong and effective governance arrangements in place. There was efficient and effective leadership and teamwork in most areas. However, the clinical governance structures in surgery were weak, with a lack of reliable information about services. There was no joined up approach or standardisation across surgical services.
Risk management, incident reporting and shared learning from these was happening across the majority of areas, with the exception of surgery. Issues affecting the smooth delivery of services or for shared learning around risks were not always discussed.
The board meetings were not attended by surgical or medical consultants. Minutes of these meetings did not demonstrate an understanding of risks that would benefit from being shared with staff.
Surgery services had new leadership, who recognised the need to engage staff in developing a strategy and improving services.
Most staff said they were respected and valued by their colleagues, and that the leadership encouraged candour, openness and honesty.
The culture in the hospital was centred on the needs and experience of people who used the service and promoted the delivery of high quality, person-centred care. However, some staff in surgical areas felt they had not been able to contribute to improvements and that concerns were not always listened to.
Where changes happened in theatres as a result of external recommendations these had been changed by subsequent external consultation. Some changes were made without staff consultation.
Local initiatives to improve patient experiences and to motivate staff were taking place through ‘listening into action’.

Areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

Improve clinical governance and risk management in the surgical directorate.
Implement promptly plans to refurbish theatres and to put in place an equipment replacement programme.
Ensure that 90% of staff receive up-to-date safeguarding and mandatory training.

In addition, the trust should:

Ensure that mental capacity assessments are completed and that consent is recorded in patient notes.
Continue to recruit to vacancies across all staff groups in all areas and ensure staffing levels are reviewed in line with increased demand for services
Ensure the environment in all clinical areas complies with national guidance and promotes privacy and dignity.
Review with staff the results of the 2014 staff survey and develop an improvement plan.
Ensure that Emergency Department patients are assessed and treated within the nationally agreed standards by an appropriately qualified member of staff.
Ensure that all equipment used by patients in the Emergency Department is clean.
Fully implement the Emergency Department computer system functionality to allow contemporaneous recording of accurate patient records and patient risk assessments.
Improve the processes for recording mortality and morbidity meetings.
Involve all relevant staff in reviewing the scheduling of operations to maximise efficiency and improve the patient experience.
Consider how it to make a trauma service available on Sundays.
Ensure that all work streams in the outpatients transformation programme are completed.
Ensure that medicines are correctly stored and are in date.
Improve bed flow between the critical care unit and medical wards.
Provide a specific risk register for end of life care.
Review resources for end of life care to provide a seven day service.
Review how it ensures patients and their families are kept informed about their care.
Develop a range of health-related leaflets in child-friendly formats for Children’s Services.
Provide a fridge suitable for the storage of expressed breast milk on Rupert Bear ward.
Ensure that the planned improvements to parent accommodation in children's services is completed on time.
Ensure that the planned maintenance work and equipment replacement in maternity are completed in a timely fashion.
Review midwifery staff's awareness of the action to take in the event of activity levels escalating outside normal working hours.
Improve the experiences of women being cared for on the gynaecology ward after a pregnancy loss.
Improve the level and range of information available to women following pregnancy loss regarding the disposal of the pregnancy remains.
Consider how to meet its internal objectives to monitor compliance with guidelines on an annual basis.

We saw several areas of outstanding practice, including:

The Specialist Palliative Care team had engaged with the public and staff to inform the development of the ‘care of the dying person care plan.’ This included new prescribing guidance for symptoms that occur at the end of life, as well as new medical guidance.
The trust was involved in the LEGACY study for secondary breast cancer, in collaboration with the Royal Marsden and the Institute of Cancer Research. The objectives of the LEGACY study are to provide researchers with the best opportunity to understand secondary breast cancer, how it works and how to stop it.
The diabetes team for children and young people was recognised for providing excellent care.
The special care baby unit had level 2 UNICEF accredited baby-friendly status where breast feeding was actively encouraged and mothers were given every opportunity to breast feed their babies.
The urogynaecology and pelvic floor reconstruction unit at Croydon Healthcare had an international profile in relation to research, provided courses to the obstetric community and had won many awards.
The maternity service was currently developing and piloting a programme of antenatal courses designed to support women with limited English.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Croydon University Hospital is the main acute hospital managed by Croydon Health Services NHS Trust. It has 565 inpatient beds, a 24-hour A&E, maternity and children’s departments, and a range of other services. It serves a large and diverse local population with one of the highest black and minority ethnic populations in South London. The trust employs around 3,500 staff and has a budget of £244 million. The UK Border Agency has its main reporting centre in Croydon and a high number of immigrants live locally and need healthcare support.

We chose to inspect Croydon as one of the Chief Inspector of Hospitals’ first new inspections due to risks identified by our ‘Intelligent Monitoring’ and resulting concerns about the quality of care. We were particularly worried about poor patient experience. The trust’s scores in the national inpatient survey for 2012/13 were among the worst in the country. This information, along with feedback from people who used the service and information from Croydon Healthwatch, and local Clinical Commissioning Groups, helped us decide where to look during our inspection.

Our inspection team of 25 included CQC inspectors and analysts, doctors, nurses, patient ‘experts by experience’ and senior NHS managers. The team spent several days on site observing care, talking to patients and staff, and looking at records and patient feedback. We held a public listening event in Croydon, which was attended by around 90 people who had used the hospital’s services. We also carried out unannounced inspections of areas where we thought there was a risk of poor care.

We consider that A&E must be improved. While staff employed by Croydon University Hospital were well-motivated and tried hard to make the arrangement work, the department has high staff vacancies and the environment in A&E made it hard for staff to deliver good care. The building was badly laid out and lines of sight were poor. The trust has applied for funding to rebuild its A&E and we believe this would make a big difference to patient experience.

In addition we had serious concerns about A&E and the way in which patients move between the Urgent Care Centre (UCC), which sees people when they first arrive, and the hospital. The UCC is run by another provider against whom we are taking action. The commissioners of this service must ensure that what they commission meets the needs of local people.

Staffing has been a problem for this trust for many years. This is being tackled by a major recruitment drive and staff in many parts of the hospital said that the situation was improving. We did, however, have concerns about staffing in older people’s wards. These wards were busy, and both staff and patients recognised that care was poor because of a lack of enough staff with the right mix of skills.

The quality of medical care (across wards for older people, people who have had a stroke, people with diabetes and similar) was mixed. Some wards were well-led and were delivering safe, effective care but others were under pressure and more needed to be done to ensure the basics were done well – for example, helping people who have dementia to choose their meals, and ensuring good infection control.

Maternity and children’s services were caring, safe and well-led. Mothers, parents and other relatives were largely positive about the care they had received, felt supported to make choices, and were kept informed about what was going on. Care was largely responsive to people’s needs . However, we saw that the inpatients ward for children was cramped.

We saw evidence that surgery was generally safe and effective, with recent improvements in staffing numbers reflected in positive staff and patient feedback. We did, however, see good practice around the use of a safe surgery checklist.On one ward staff said more support was needed to ensure they could manage the range of specialities effectively. End of life care was also well-run, with appropriate links made with the local hospice, and multi-disciplinary teams working to make sure people’s needs were met.

More can be done to ensure the Critical Care Unit is delivering consistently safe and effective care. There was too much reliance on non-permanent staff outside of core hours and the unit was cramped.

The trust can do more to become a learning organisation and learn from audits, its own performance data, and best practice guidelines. Some service areas were let down by a lack of attention to basics such as ensuring patients were appropriately dressed before going home, care planning and record keeping.

The hospital‘s senior team has been through a lot of change. All of the executive team – with the exception of the Director of Nursing – have been in post less than a year. Many of the welcome changes at Croydon have been driven by the Chief Executive and the new team. Staff went out of their way to tell us about this.

We saw evidence that many staff from all professional backgrounds were committed to working with the new team to drive up quality. Patients had noticed this and it was reflected in feedback we got, although it is clear the trust has a history and reputation that is making it hard for it to move forward. We also heard about recent incidents at our public listening event that confirm the trust has many challenges ahead.

In summary:

This is a new management team that is working to change culture (through the ‘listening into action’ programme,’ which is working well). It is early days but the new team is having an impact.
The A&E unit is not consistently providing safe care, mainly because of relationships with the UCC run by another provider (against which we are taking action).
Poor patient experience is still a theme across the trust, and the hospital needs to continue its work to improve this.

Staffing has been a problem for this trust for many years and this is being addressed through a major recruitment drive. There are still significant staffing problems in A&E and on the older people’s wards.

We reviewed the services within the Emergency Department (ED) and the Acute Medical Unit (AMU) of Croydon University Hospital. Our findings relate only to those two areas. Urgent care services within the hospital are hosted by Assura Wandle LLP. As these two services co-exist within the same building they have a direct relationship on each other's function. Therefore an inspection of the Urgent Care Centre (UCC) was undertaken at the same time.

During our inspection we saw several examples of good care and all of the people that we spoke with told us that they had been very happy with the treatment that they had received. People told us staff were 'very kind and caring' and kept them informed about why they were waiting. They considered that they had been involved in decisions that were made about their care.

However, we did find evidence that people's needs were not always being met in a way that was safe and effective. We judged that the skills and expertise of staff was not always sufficient to meet people's needs and keep them safe. We also raised concerns about the potential safety of people who were treated in the ED having initially been assessed in the UCC. We also raised concerns about the state of disrepair of the department.

As a result of our inspection we have identified shortfalls in three of the essential standards which all hospitals are required to comply with.

We spoke to six patients and all of them told us the surgical procedure they were about to undergo had been explained to them and staff had made them feel at ease. They told us that all of the staff that they had come into contact with at the hospital had treated them with respect. One patient said 'Staff have been reassuring and as good as you would hope them to be.' Another patient said 'They are marvellous but work very hard. I'm amazed at the amount of paper work they have to do.'

We saw that patients had their privacy protected during all stages whilst in theatre. All grades of staff ensured patients were covered with blankets and drapes when being transferred from bed to theatre table and whilst being prepared for their operation.

We observed staff interacting with patients in a kind and courteous manner. The language and tone of voice used by staff when talking to patients was always appropriate and was clearly intended to put people at their ease.

This inspection was carried out under section 62 of the Health & Social Care Act 2008. We performed this inspection to check on action taken by the trust following warning notices imposed at our previous inspection in June 2012. At that time the trust had experienced four serious incidents, classified as 'never events' within the theatre areas at the hospital. 'Never events' are defined by the NHS National Patient Safety Agency (NPSA) as 'Serious, largely preventable, patient safety incidents that should not occur if the available preventative measures have been implemented.'

During our visit, we went into six theatres (Main theatre 2, 10, 6 and the ophthalmology theatre). We also visited theatres 1 and 4 within the day surgery department. We did not visit the maternity theatres as there was no elective surgery planned that day.

We watched the various stages of fifteen theatre checklist techniques being performed. We saw three sign in checks, seven time outs checks and three sign outs. The checklist identifies three phases of an operation, each corresponding to a specific period in the normal flow of work as follows: Before the patient has the anaesthetic ('sign in'), before the operation starts ('time out') and before the patient leaves the operating room ('sign out').

Part of the inspection was also to check on availability of equipment within the hospital overall as we had concerns during our last visit about the lack of equipment in some parts of the hospital. We visited the maternity unit, three wards and the accident and emergency department to check on equipment levels.

A team of representatives, from the Care Quality Commission, visited Croydon University Hospital as part of a planned review of compliance. The team included compliance inspectors, a compliance manager, analysts and a professional clinical advisor.

Over the course of four days we visited ten wards, including the maternity unit, the Accident and Emergency Department (A&E) and the discharge lounge. A team of inspectors, with the professional clinical advisor spent a day in the hospitals operating theatre suite.

We spoke with patients and members of staff, both clinical and non clinical, asking them about their views of the service. We looked at a sample of records including care plans and staff training records. Our analyst team also looked at information relating to staff rotas, complaints and notifications.

On wards caring for older people we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who are not able to talk with us.

We also had meetings with the chief executive officer and senior managers in the trust and asked them for a range of further evidence relating to staffing levels, staff training, notifications, patient feedback and complaints.

All of the staff that we spoke with were welcoming, open, and receptive to the inspection process. We would like to thank them for their help.

Individual patient feedback on the wards that we visited was, in the main, positive.

Comments included 'staff are wonderful', 'all the staff are very good here', and 'I could not speak more highly of staff, and they're a really good bunch'.

However, we did receive some adverse comments from patients, regarding staff attitude, saying 'staff are sometimes a bit cold or dismissive although never unkind'. We reported this to the ward managers and we were assured that it would be addressed.

The perception of many people was that there were not enough staff and they told us 'staff are constantly busy', there never seems to be enough of them' and 'the nurses seem to be able to cope most days but you can see that they're stretched'.

We observed one example of a shortage of staff impacting on the care of one patient and were told about others.

On the maternity unit women told us their care had been 'very good', 'excellent and a good experience'. They said the midwives and doctors had 'been calm and reassuring', 'stayed with me and made sure I understood what was happening', and 'helped me to stay calm when I was so worried'.

Throughout the hospital we observed patients being cared for in a kind and respectful way. All levels of staff within the hospital showed respect when they were addressing patients and we heard examples of them checking that patients were comfortable and understood what was happening.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We made an unannounced visit to Croydon University Hospital on 22 November 2011 and spoke to people in Accident and Emergency (A&E), Queens 2, Wandle 3, Purley 3, Heathfield 2, and Rupert Bear wards.

A public interest disclosure letter had been received by the Care Quality Commission (CQC) prior to the visit taking place. As the regulator, CQC considered these concerns and other information received about the service since our last review.

The majority of people we spoke to said that they had been given good information about their care and confirmed that everything had been explained to them. We observed curtains consistently pulled around beds for privacy and staff interacted with people in a calm and respectful manner during our visit.

We spent time on two wards caring for older people and spoke to a number of people and their visitors who all reported they had been treated with dignity and respect. Comments included, "they are all nice ' very polite", "they have been so kind" and "they are overworked but I find them all very very good".

Individuals generally felt that staff worked very hard however they made comments about staff being "overstretched", "hard pressed" and "overworked". One of the people using the service felt that there were not enough staff particularly when caring for people who have dementia. This view was shared by some of the staff and a visitor whose relative was living with dementia.

Feedback from other wards was that staff were hard working and were generally available when needed. They also told us that staff members were friendly and helpful. Individuals who had attended the hospital in previous years reported that there had been an improvement in staff attitudes.

On balance, the people we spoke to were generally positive about the care that they received at Croydon University Hospital although the majority also made comments about how busy or overstretched staff were.

All of the people we spoke to about cleanliness and hygiene reported that the wards were always kept very clean. Patients commonly described cleanliness within the hospital as "very good".

We would like to thank all of the staff and people who helped to facilitate this review and share their experiences.

We visited Croydon University Hospital maternity department on two separate occasions as part of this review. We acknowledge that on 14 July 2011 the unit was relatively quiet and on 5 October 2011 the unit was busy.

We would like to thank all of the staff and people who helped to facilitate this review

and share their experiences.

During our visits to Croydon University Hospital maternity unit on 14 July and 5 October 2011 we spoke to people on the postnatal ward. Overall the feedback from patients was positive with them all feeling that they had received good care and that the staff were kind, helpful and respectful of their dignity. They were positive regarding their births and reported that they were given information and involved in decisions during labour.

On 5 October we spoke to some patients on the antenatal ward who had already given birth, but were on this ward because the postnatal ward was full. All of these patients were positive about the information they had received on the labour ward, however some women said they had not had any information since being on the antenatal ward.

In terms of care on the postnatal ward, the women said that staff were around less during the night, although they attributed this to staff giving them time to sleep. They said that staff responded quickly if called for and would provide more support if asked.

All four patients we spoke to reported that they had received pain relief when they wanted and were happy with that part of the service. However one "Just a Minute" (JAM) - feedback cards available for people to complete - for the postnatal ward stated,

"Postnatal care on readmission has been good. However on occasion have had to ask 2-3 times for pain relief before being attended to."

The majority of JAM cards that had been completed the week prior to our visit on 14 July 2011 contained positive feedback about the quality of care. Comments included,

"Quality of the care given by all the staff. All my needs and baby's needs were met."

"Mid-wife was very helpful and supportive. She made the delivery very easy. Very happy."

During our visit on 5 October we received more mixed views from people about their care. The majority of women on the postnatal ward reported having 1:1 care throughout their labour and were positive about the care they received during labour. All patients said that they received the pain relief they wanted and without delay. In terms of care on the postnatal ward, patients thought that staff were not around very much. They said they were helpful when they were available and the care patients had received was good. However, one patient said that she had been told by a midwife that she would be washed, but that it hadn't happened. Another patient asked for pain relief, but it didn't arrive and she had to call again.

However some of the women who had already given birth, but were on the antenatal ward because the postnatal ward was full, were not happy with the care they had received on this ward. They told us they had not been seen by staff and one of the patients was particularly concerned as her baby was supposed to be monitored four hourly and it hadn't been happening, despite their requests.

We looked at complaints received and noted the number increased following the publication of our review in April 2011 and CQC were contacted directly by two people with concerns about care they, or a family member, had received. However the number of complaints has levelled off to below expected numbers in recent months. The majority of complaints related to aspects of clinical treatment.

We did not receive any negative comments from people we spoke to about the maternity unit environment. One person attending an appointment at the birthing unit particularly liked the way it was decorated to create a homely environment.

Overall patients we spoke to on our visit were positive about their care and treatment.

However the patients we spoke to commented that they did not feel involved in decisions about their care and did not know who to complain to. Most had not been provided with written information about the wards they were on.

We generally received positive feedback from patients about mealtimes, although two people did not like the food. Patients told us they were given choices of food and drink. We were also told that the food was always hot and fresh water was provided every day. Feedback included, 'it's quite a good choice', 'I don't eat fish ' they know that', and 'no complaints'.

During our visit to Croydon University Hospital maternity unit we spoke to patients and their relatives about their experiences of receiving care. One person told us that their experience had been, "Not as good this time", in comparison to having previous children at the hospital. Whereas another person told us, "They are looking after me well' and "it's good".

Other people talked to us about the poor experience they had throughout their time in the maternity unit. Some comments included

'When you press the buzzer, they take time to come. Not happy to help.' Asked more than 5 people and they didn't come back. 'Just want to check baby'.

'At night, they don't walk around to check on you.'

'Nobody has changed the [drinking] water since yesterday.'

'Attitude of the staff is horrible.' 'Only midwife has been nice.'

'Customer care zero. Patient care zero.'

'Hospital has changed name, but needs to change its service.'

People on the post natal ward gave us the following feedback about the environment, "I like having a single room".

"it's been lovely ' very quiet".

People we spoke to said, "The staff are friendly enough", "All very nice", and "always offering help".

During our visit we were shown the "Just a minute" cards for the ante natal ward in January 2011. These were overwhelmingly positive and included the following comments: "friendly staff", "nurses were very helpful", "I'm being well looked after", "staff were excellent, "compassionate and caring", and "staff are very kind".

We also looked at comments in the book on the postnatal ward. Comments included, "Was really pleased with my stay at Mayday ' treated really good by all the staff'. "Staff were friendly and approachable and tried to help all the ward occupants". "Pleased with the midwifery team".

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.

All Inspections

Safe

Effective

Caring

Responsive

Well led

Professor Sir Mike Richards