The Care Quality Commission
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Croydon Health Services NHS Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings

All Inspections

08 October to 25 October

During a routine inspection

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

We rated safe, effective, caring, responsive and well-led as requires improvement.

trust, we took into account the current ratings of the services not inspected this time.

10 July 2018

During an inspection looking at part of the service

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

  • We rated safe, effective, responsive and well-led as requires improvement and caring as good. We rated three of the trust’s 11 services as requires improvement. In rating the trust, we took into account the current ratings of the eight services not inspected this time.
  • In medical care there were large number of outliers and patients being moved at night.
  • The medical care 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.
  • Some concerns that had been found at the June 2016 inspection of community services for adults had not been resolved including insufficient speech and language staff and waiting times for access to the domiciliary speech and language team. There were also issues with staffing numbers in medical care.
  • The trusts own internal audit data for hand hygiene within the medical care 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 within the medical care service 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.
  • In community services for children and young people (CYP) we found the caseload numbers were well above the recommended number for health visitors to safely manage. This was a finding at the inspection in June 2016.
  • Multidisciplinary working was not fully embedded in all services for CYP.
  • Processes to monitor and review the quality of care in CYP services were not robust and in services for adults the trust did not provide outcome data for adults.
  • Services for CYP were not planned to meet all of their needs and within national timescales.
  • Performance for CYP services had been below national and local indicators for the last twelve months.
  • The roll out phones for community adult nurses was not complete and some staff were using their own phones which potentially compromised their safety and was a data protection risk.
  • In both community services we found there was a lack of use of interpreters and an over reliance on family members to interpret which is not line with best practice.
  • Patient information leaflets were not always available in different languages if requested.

However:

  • There was a clear leadership structure within the medical care core service.
  • Within the medical care core service there was a culture of honesty, openness and transparency. 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.
  • 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
  • In medical care, 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 medical care core 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.
  • Both community services provided care and treatment that was informed by national guidance.
  • There was effective multidisciplinary working in both community services for adults and medical care.
  • Staff understood and knew how to protect adults and CYP from abuse.
  • Staff had access to training and were competent to carry out their role.
  • Adults and CYP using the community services were positive about the care they received and told us they were involved in decisions about their care. They told us staff treated them with kindness and compassion.
  • In both community services, staff were positive about the local and executive leadership of the trust. They felt valued and told us there was a supportive culture.

10 July 2018

During an inspection of Community health services for adults

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

  • Staffing levels were consistently lower than the recommended numbers for the domiciliary speech and language therapy (SALT) team. This had not improved since the last inspection.
  • The trust did not have integrated electronic patient record systems to enable a shared care record. This had not improved since the last inspection.
  • The service did not always take account of patients’ individual needs. Information on how to access services and other information leaflets were not easily accessible in other languages. Staff told us they regularly used relatives to translate during drop in sessions.
  • The service was not meeting referral to treatment times. This was a significant issue for the domiciliary SALT team and there had been no improvement since the last inspection.
  • The service did not always have a satisfactory system to book appointments. In a podiatry clinic, patients were required to ring and book their next appointment and this posed a risk that a person may forget to do this.
  • The trust did not ensure that all staff had the equipment they required to work safely. The trust’s roll out of phone to the community nurses teams had not been completed.
  • The trust did not ensure that patients always had access to interpreters when required.
  • The use of personal phones by staff to contact patients presented a significant data protection risk.
  • Some of the data provided by the trust lacked depth and granularity, in particular staffing and audit information. The service did not provide sufficient data around patient outcomes and therefore missed opportunities to identify potential risks to patients.

However:

  • The service managed patient safety incidents well. Incidents were reported and investigated appropriately. Lessons learned were shared across teams and the wider service.
  • Staff kept appropriate records, paper and electronic, of patients’ care and treatment. Records were clear and up to date.
  • Staff carried out risk assessments for all patients on initial and subsequent visits. Appropriate assessment tools were used to identify and help manage patient risks.
  • Clinical rooms we visited were clean and tidy. We saw evidence of regular and compliant infection control audits across the community adults services.
  • Multidisciplinary working was embedded across community adult services.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • The service made sure staff were competent for their roles. Staff were well trained, received appropriate supervisions and showed overall good compliance for appraisal rates.
  • Staff encouraged patients to proactively manage their own health. Staff were passionate about supporting patients to improve their own health and wellbeing.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated patients kindly and with dignity.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • All staff we spoke with told us that there was an open and honest culture. Staff were encouraged to report incidents and there was a no blame culture when incidents were reported.

10 July 2018

During an inspection of Community health services for children, young people and families

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

  • The service did not always comply with infection control policies. Staff were not always adhering to the bare below the elbow policy and audits findings were not always actioned.
  • The caseload numbers for health visitors was consistently higher than the recommended numbers. This had not improved since the last inspection.
  • The multidisciplinary working was not fully embedded in the child development centre. This was an ongoing concern since 2016.
  • We did not see evidence that that all services monitored the effectiveness of care and treatment and used the findings to improve them. They did not compare local results with those of other services to learn from them.
  • The service was not consistently meeting the national and local targets for completion of assessments within a set timescale.
  • The service did not have a policy in place to coordinate the transition between children and adult services that covered all the services offered. Where transition plans were in place, this did not comply with National Institute for Health and Care Excellence (NICE) guidance for when this process should start.
  • The service did not consistently plan and provide all services in a way that met the needs of all local people.
  • The service did not always take account of patients’ individual needs. Information on how to access services and other information leaflets were not available in other languages. Staff told us they regularly use relatives to interpret during drop in sessions.
  • Although a risk register was in place, we did not see evidence actions had been taken to mitigate these risks to an acceptable level.
  • The trust collected, analysed, managed and used information to monitor performance against local indicators. However performance for health visitors had been below the expected national and local indicators for the last 12 months.
  • The audit process was not well embedded to assure the leadership team that services were being provided in line local and national guidelines. There was limited audit activity and the actions from audit findings were not consistently followed through.

However:

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
  • Staff kept appropriate records electronic record of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care via mobile devices at the point of care.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • Staff had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system that they could all update.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Staff were aware of guidelines relevant to their service.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Staff provided emotional support to patients to minimise their distress.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff were complimentary of the local leadership team.
  • The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

16-19 June 2015

During a routine inspection

Croydon Health Services NHS Trust provides services to over 380,000 people  across the borough of Croydon either in patient’s own homes or from clinics and specialist centres, including Croydon University Hospital and Purley War Memorial Hospital in Purley.

The trust has 670 beds including 589 general and acute, 66 maternity beds and 15 critical care beds. The Emergency Department is at Croydon University Hospital. There are 17 community locations including the Purley War Memorial Hospital which does not have any inpatient beds.

All core services are provided at Croydon University Hospital with outpatient, phlebotomy and imaging services provided at Purley War Memorial Hospital.

During 2014/2015 the trust received 67,159 emergency attendances, 3,047 inpatient admissions and 324,440 outpatient attendances.

The trust provides services to a population from the significantly deprived borough of Croydon

We carried out an announced inspection between 16 and 19 June 2015. We also undertook unannounced visits to the Croydon University Hospital on 23 June 2015 and community services on 30 June 2015.

This was the first inspection of Croydon Health Services NHS Trust under the new methodology, however we had previously inspected Croydon University Hospital in September 2013. At that inspection we found concerns with the care patients received in outpatients and on wards for older people including staffing levels and how their discharge was managed.

Since our last inspection, in September 2013, the trust has made significant improvements and this progress needs to continue. Overall, this trust requires improvement.

We found that Croydon University Hospital and community services for adults and children and young people and families require improvement.

Our key findings were as follows:

Safe

  • The trust had an incident reporting process but not all staff were reporting incidents and the trust was reporting less incidents than trusts of a similar size.  Feedback and learning from incidents was inconsistent.
  • Effective infection prevention and control procedures were in place. Availability and replacement of equipment and the environment in some clinical areas  potentially compromised patient care.
  • Staff working inpatient and community services were using different IT systems to record patient care. Although many aspects of it were working well staff in some services were continuing to use paper records until the problems had been resolved or the systems could be integrated.
  • Staff attendance at mandatory training including safeguarding vulnerable adults and children varied across services and needed to improve.
  • Although staffing levels had improved, vacancies across all staff groups, nurses, doctors and allied health professionals remained an issue and recruitment was on-going. To maintain safe staffing levels the trust used locum and bank and agency staff.

Effective

  • Patients received care that was informed by best practice policies and guidelines.
  • National audits performance was largely positive.
  • Adults and children had their pain assessed and effectively managed and their nutritional needs were met.
  • The number of staff who had had an appraisal varied across the trust and attendance at mandatory was below the trust target in several services.  
  • Staff had attended training on consent, the Mental Capacity Act 2005 and Deprivation of Liberty Standards but information was not always recorded in patients' notes.

Caring

  • In the 2015 In patient survey some of the trust's results were worse than other trusts. However,  the patients and families we spoke with told us they received compassionate care and were treated with dignity and respect.
  • The majority of relatives and patients we spoke with said they were involved in decisions about their care and treatment.
  • The trust had a multi-faith chaplaincy service available to support patients, relatives and carers.  

Responsive

  • The trust has made good progress in developing both its inpatient and community services to meet the needs of the local population, particularly for vulnerable people.
  • It has improved its performance in some services in relation to patients being able to access care and treatment in line with national standards, but it continues to face challenges in others, including community services, surgery and critical care.  In surgery operations were cancelled and day surgery was not always able to cope with the high level of activity and patients were delayed being discharged from critical care.
  •  Although the trust has not always met the 95% standard for all patients to be seen within four hours in the emergency department, it's performance is better than the national average.
  • The quality and timeliness of responses to complaints has improved.

Well-led

  • The trust has a vision for how services can be further improved to meet the needs of the population but more work is required in how the vision can be translated into reality. 
  • Systems to monitor the quality and safety of services were still evolving and need to be strengthened.
  • Public and staff engagement has improved and the majority of staff we spoke with were positive about working at the trust and acknowledged the improvements that had been made.

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

Importantly, the trust must:

Trust wide

  • Continue to improve and embed systems to monitor the quality and safety of care provided.

At Croydon University Hospital

  • 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:

Trust wide

Continue its programme of work to resolve the IT problems and consider how it can integrate systems across community and inpatient services.

At Croydon University Hospital

  • 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.

In Community Services for adults

  • There are insufficient numbers of speech and language therapists to meet the needs of the population.
  • Medicines are stored, handled and administered appropriately and safely.
  • Patients suffering from stroke should be seen within 48 hours of discharge from hospital along with patients receiving care from the community intermediate care team
  • Considers how it can integrate the hospital and community IT system to enable a shared care record.

In Community services for children, young people and their families

  • The provider should ensure that clinical governance processes are embedded across local community teams.
  • An internal audit programme should be developed to ensure services formally evaluate and improve service provision.

We saw several areas of outstanding practice including:

    At Croydon University Hospital

  • 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.

Community services for adults

  • Patients received care and treatment in a personalised and holistic way. Staff followed guidelines from the National Institute for Health and Care Excellence (NICE) and other professional bodies, such as The British Association of Occupational Therapists and The Chartered Society of Physiotherapy.
  • There was 24 hour community nursing cover seven days a week. The community nurses were involved in the care of patients requiring palliative care. Patients were supported to alleviate their pain appropriately.

Community services for children, young people and their families.

  • The community nursing service provided at St Giles special school was dynamic, organised and well led. There were good examples of multidisciplinary and multi-agency working, ensuring the child was at the centre of decision-making and involved in their care. The school was bright, positive and a fun environment to work and learn.
  • The Children's Specialist Asthma Service took - an innovative approach. F for example, staff had developed social media networking to provide additional support to children with asthma aimed at maintaining good health and reducing admissions.
  • Chatterbox is a language development service for pre-school children. Speech and language therapists and children's centre staff work together to deliver targeted care to address the speech, language and communication needs of pre-school children. They provide support and advice to families, and ensure timely referrals to speech and language therapists for more specialist assessment and treatment. They also signpost to other services.
  • The children's specialist nurse diabetic service supports children and young people along with their carers to manage their disease and are part of a 24-hour helpline so parents and young people can access the advice and care they need at all times.
  • The Willow bereavement service was set up to provide counselling for terminally ill children and their siblings.

Professor Sir Mike Richards

Chief Inspector of Hospitals

16 – 19 June 2015

During an inspection of Community health services for adults

Croydon Community Health Service for Adults requires improvement.

We rated the domains Safe and Responsive as Requiring Improvement. .found th domains require improvement

There were not enough was an insufficient number of Speech And Language Therapy (SALT) staff employed to meet the high number of referrals.The trust had not always conformed to the 18-weeks waiting time target for patients referred to the Domiciliary SALT team. 

Patients suffering from stroke were not always seen by the community therapy team within two days of discharge from hospital. This meant refore the trust’s target of two days had not always been met.

The Community Intermediate Care Service saw only 30% of patients within the trust’s target time of 48 hours from referral. was 70% non-compliant with the trust’s target that patients should be seen within 48 hours of referral.

Between 1 April 2014 and 1 March 2014 84 serious incidents reported by community health services fro adults. These incidents  were all related to pressure ulcers grades three and four. Despite much attention being devoted to pressure sores, the recording of pressure sores by staff still fell short of the trust’s guidelines.

Medicines had not always been stored, handled and administered appropriately and safely. The trust’s medication policy and procedures had not been followed by staff. The medication incidents in the community service placed patients at risk of harm. A recent medication incident resulted in the disposal of £500 worth of immunisation and other medicines.

There had been ongoing problems with GPs not completing medication request forms appropriately. Patients were potentially exposed to risk due to medicines being delayed.

Staff knew how to respond to possible safeguarding issues. We noted some recent medication incidents had been referred to the safeguarding team

Currently the cluster five community nursing team had four community matron posts vacant and three of these posts had been vacant for six months. Although the trust was recruiting, it would be some time before new recruits were in post.

Patients received care and treatment in a personalised and holistic way. Staff followed guidelines from the National Institute for Health and Care Excellence (NICE) and other professional bodies. 

There was 24 hour community nursing cover seven days a week. The community nurses were involved in the care of patients requiring palliative care. Patients were supported to alleviate their pain appropriately.

There was effective multi-disciplinary team (MDT) working within the adult community service as well as with other health and social care providers.

Patients and relatives gave positive feedback of their experiences of the service. They were complimentary about the community staff and found staff caring, compassionate and respectful.

16 – 19 June 2015

During an inspection of Community health services for children, young people and families

Croydon Heath Services NHS Trust provides an integrated acute and community health service for children and young people living in the south London borough of Croydon. The trust emphasis is to provide this service when and wherever it is needed.

Croydon Health Services NHS Trust is commissioned to provide a range of services to children and young people including health visiting, school nursing, speech and language therapy, and hospital at home services, which includes; a specialist asthma service, ; a community nursing team, ; a diabetes team; , special school nursing team; , community nursing service for children with special needs, ; specialist learning disability nurse, ; continuing care assessments, ; and a palliative and end of life care team, including the bereavement service called Willow. There is also the multidisciplinary team that works out of the Crystal Children’s Centre, which includes community paediatricians, physiotherapy, occupational therapy and an audiology team. There is a family nurse partnership practitioner (FNP), a Looked a After Children (LAC) team and a safeguarding team.

We inspected the following regulated activities that the trust is registered with CQC to provide:

• Diagnostic and screening procedures.

• Treatment of disease, disorder or injury.

Children and young people and their carers received safe services from Croydon Health services NHS trust and a were protected from harm and abuse. Staff understood their responsibilities to raise concerns and to record and report safety incidents. Lessons were learned from incidents and action was taken to improve the service. Staff demonstrated a good awareness of safeguarding issues and knew the procedures to follow if abuse was alleged or suspected.

Staffing levels were too low under-resourced in some areas and caseloads were high. However, services were continually ously reviewed to ensure that children and young people received safe care and treatment.

Children and young people in Croydon had care and treatment provided in line with legislation, best practice and evidence -based guidance. The outcomes of care and treatment were evaluated at a local level and within specific services. There was limited participation in national and local audits and no trust audit department driving improvements within this core service. Where audits were undertaken, the results were used to improve outcomes for children and young people using the service.

Children, young people and their families were involved in making decisions about their care and treatment. Staff showed a sound awareness of why, when and how consent should be sought.

Staff had the relevant skills, knowledge and experience to deliver effective care and treatment. Staff were supported through supervision and annual appraisal, and personal development was encouraged, although not always facilitated when required.

There was collaborative and effective multi-disciplinary and multi-agency working to understand and meet the needs of children and young people using the service. This included the arrangements for young people moving to adult services.

Children, young people and their families were treated with dignity, respect and kindness. Staff ensured that children, young people and their families understood and were involved in their care and treatment.

Children, young people and their families were positive about the care and treatment they had received and about the staff providing the service.

Children and young people’s services were planned and delivered to take account of the needs of the local population and of individual needs. Access to care was good, with waiting times from referral to first appointment well within the trust’s target of 18 weeks.

Complaints and concerns were taken seriously. Information about how to make a complaint was displayed in the clinics we visited.

Communication within teams was good and staff felt supported by their immediate line manager. Staff felt confident that issues and concerns could be discussed with their line manager but were not convinced that the T trust E executives would be as supportive.

Governance is not embedded within the community, children and young people’s services and staff were unaware of the governance structure and knew little about clinical governance. Clinical audits only occurred where services were innovative and motivated to do so. There was no internal audit plan other than the two mandatory audits.

The executive team were not visible within the community but staff felt the trust was ‘getting there’. Most staff were aware of the l Listening into a Action events but few had participated and felt these were more aimed at hospital services.

There was a lack of involvement of people who use services in the planning and delivery of new services.

During the inspection we held focus groups with health visitors and spoke to seven 7 parents and children. We reviewed individual care plans, risk assessments and a variety of team- specific and individual service -based documents.

We sought feedback from external partner organisations and reviewed online feedback.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.