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Croydon University Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 October 2015

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

Inspection areas

Safe

Requires improvement

Updated 7 October 2015

Effective

Good

Updated 7 October 2015

Caring

Good

Updated 7 October 2015

Responsive

Requires improvement

Updated 7 October 2015

Well-led

Requires improvement

Updated 7 October 2015

Checks on specific services

Maternity and gynaecology

Good

Updated 7 October 2015

We found that maternity and gynaecology services were provided to a good standard. There had been continued and sustained improvements to maternity services. Women who had previously given birth at the hospital commented positively on the improvements to maternity services and told us staff were caring, responsive and knowledgeable.

We found an integrated clinical governance system in use and action was taken when non-compliance with standards was identified. The risk register was active and regularly updated and plans for mitigation put in place pending action to eliminate the risk. Information about performance and risk was communicated through the governance arrangements to the trust board. 

There were robust arrangements in place for recording adverse events and near misses, and investigating and learning from these. There was an expectation of openness and honesty. When outcomes were worse than expected, staff met women, and their families when appropriate, to provide a full explanation.

Staff did not always complete the required safety related mandatory training.

Agreed staffing levels were appropriate to meet current demand. However, improvements were needed in the use of the maternity services escalation policy at busy times. New staff were well supported, and there was a comprehensive mandatory training programme, with opportunities for development. The directorate had identified that appraisal rates for midwifery staff were low and action had been taken to improve this. Staff we spoke with said there was effective communication in maternity and gynaecology services.

There was easy access to services for women and there individualised care plans were developed for each woman.

There was adherence to good practice guidelines and outcomes for women met expectations.

Medical care

Requires improvement

Updated 7 October 2015

Medical care (including older people’s care)

Updated 7 October 2015

Patients were kept safe whilst they were receiving medical treatment and care. Patients who were at risk of deteriorating were monitored and there were systems to ensure that appropriate medical or specialist nurses responded.

There was an open culture, with learning from clinical incidents. There were enough doctors and nurses available to keep people safe.

Although the trust found it difficult to recruit and retain nursing staff, it was able to fill gaps effectively using bank staff.

Care was provided in line with national and local best practice guidelines. Clinical audits had been undertaken, and national and local audit demonstrated good outcomes for patients, with the exception of diabetes care and treatment.

We observed good clinical practice by clinicians. Patient morbidity and mortality outcomes were broadly within what would be expected for a hospital of this size and complexity and no mortality outliers had been identified.

Although staff had a good knowledge of the issues around capacity and consent, the trust was unable to provide any assurance that capacity assessments were always being carried out when needed and that consent was being recorded in medical notes.

Patients received compassionate care and were treated with dignity and respect. Most of the patients and relatives we spoke with said they felt involved in their care and were full of praise for the staff looking after them. A number of patients raised concerns that they were not always kept informed about their treatment.

The medical services had mixed results in patient surveys but results indicated an improvement in the views of patients over the last 12 months. The medical division was effective at responding to the needs of its community and very responsive to its elderly community.

The hospital operational management team had an excellent grip on the status of the hospital at any given time. Bed availability was well managed. Discharges were still not fully effective, with patients waiting too long in the discharge lounge and waiting too long for their prescriptions.

Elderly care pathways had been well designed to ensure that elderly patients were assessed and supported with all their medical and social needs. Patients who were living with dementia were accommodated on two specifically adapted ‘dementia friendly’ wards.

The hospital had designed pathways that, where if possible, kept patients out of the Emergency Department. The Ambulatory Care Unit provided effective alternate pathways for GPs and other referrers.

The medical services were very well led; divisional senior managers had a clear understanding of the key risks and issues in their area. The medical areas had an effective meeting structure for managing the key clinical and non-clinical operational issues on a day-to-day basis.

The hospital had a risk register that covered key risks but was still being developed to accommodate the recent changes to the divisional structure.

There was a clear drive and enthusiasm among managers to innovate services for patients and particularly elderly patients. Staff spoke positively about the high quality care and services they provided for patients and were proud to work for the hospital. They described the hospital as a good place to work and as having an open culture. The most consistent comment we received was that the hospital was a friendly place to work and people enjoyed working with their teams.

Urgent and emergency services (A&E)

Good

Updated 7 October 2015

Overall, we have rated the Accident and Emergency Department also known as the Emergency Department (ED) at Croydon University Hospital as good. Staff who worked in the department demonstrated a multi-disciplinary approach to caring for their patients. They worked cohesively together, respecting each other’s skills, experience and competencies in a professional manner that benefited the patients they cared for.

Safety in the department required improvement. The environment did not always enhance patient safety and equipment was not always cleaned properly.

Patients arriving by ambulance were assessed and treated quickly but other patients were not always clinically assessed as soon as they arrived in the department. It was possible for their condition to deteriorate while they were waiting to be seen. This was partly caused by the fact that the Emergency Department shared reception facilities with the adjacent urgent care centre, which was run by another organisation. On arrival at the reception, some patients were sent in error to the urgent care centre, which had an adverse impact on some of their patients.

Staffing levels for both medical and nursing staff also needed to improve. Care and treatment was effective and delivered in line with current evidence based guidance and standards. The trust used national and local clinical audits to monitor the effectiveness of care and treatment.

The department was responsive to the needs of local people and had particularly good facilities for patients with dementia. The ED was better than many other hospitals in meeting the national target of admitting or discharging 95% of patients within four hours. The department itself was well-led. The leadership actively shaped the culture through effective engagement with staff and patients. They Demonstrated the skills, knowledge and experience needed for their roles.

Surgery

Requires improvement

Updated 7 October 2015

The clinical governance structures in surgery were weak and there was a lack of reliable information about the performance of services. The services were disjointed and suffered from a lack of standardisation. There was good team work within specific parts of the service, but communication was sometimes weak, with few forums for multidisciplinary discussion of issues affecting the smooth delivery of services or for shared learning.

Service related risks were not always formally identified and addressed. Where risks had been recognised, such as faulty theatre equipment and poor theatre environment these were being addressed. However, the promptness of resolving some risks was often slow, and there remained a lack of a shared understanding of risks and how these should be tackled and monitored.

Equipment was not always readily available to support the delivery of services, which combined with equipment failures impacted on patient safety and cancellations.

The investigation of serious incidents and the response to complaints had improved, but it was not clear that incidents were being consistently reported, categorised, or learned from.

Staff did not always complete the required safety related mandatory training. However, new staff and doctors in training were well supported.

Initiatives, such as the opening of a surgical assessment unit, demonstrated a desire to improve patient experience, but the unit was not yet able to follow the operating policy.

Patients praised the responsiveness and kindness of staff on the wards. Patients we spoke with who had been to the hospital before remarked on improvements in the attitude of staff and the efficiency of services. Patients' individual needs were generally met and there was excellent practice to ensure that patients with learning disabilities received responsive and effective care.

Surgery services adhered to best practice standards, and staff had worked hard to reduce referral to treatment waiting times. Care pathways for patients were enhanced by multidisciplinary working with specialist nurses and links with the trust community health services.

Outcomes, such as readmissions following surgery were generally in line with or better than the national average except for emergency trauma and orthopaedic surgery. There had been notable improvements since our last inspection in infection control processes and aspects of patient care.

The trust performed poorly in the cancer patient experience survey results for inpatient stays. They were in the top 20% of trusts for three areas, but were in the bottom 20% of trusts for 19 areas.

Discharge was better coordinated, but there remained some blockages in the process, such as the lack of rehabilitation beds in the community.

A new electronic patient record system had been effectively implemented. There were some disruptions to the service at times, which were being addressed.

Following a recent restructuring, surgery services had new leadership, who understood the need to engage staff in developing a strategy and improving services.

Intensive/critical care

Requires improvement

Updated 7 October 2015

The critical care service required improvement in a number of areas but was going in a positive direction. There were a few issues, particularly with medicines management, the environment of the unit, staffing skill mix, both nursing and medical, and discharges. Performance monitoring also needed to improve. However, patient feedback and observations of care were positive.

The unit mostly learned from incidents, national guidelines were mostly met, and infection control was improving despite being challenged by the environment.

Governance arrangements were clear and the new leadership team were valued and approachable.

There were appropriate relatives' facilities and support for people in vulnerable circumstances.

Patient outcomes were mostly around the national average and the outreach team were having a positive impact on these in the rest of the hospital.

Services for children & young people

Good

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.

End of life care

Requires improvement

Updated 7 October 2015

The end of life care (EoLC) service at Croydon University Hospital (CUH) had a track record of steady improvements in patient safety. There were systems to ensure an appropriate review or investigation and lessons learned were communicated widely to support improvement across the trust.

Risks to patients were assessed, monitored and managed on a day-to-day basis. We found issues with the consistency of staff recording 'do not attempt cardiopulmonary resuscitation' (DNA CPR) form on the trust's electronic patient records (EPR). Some staff were also unable to open the DNA CPR records on patient's EPR.

Openness and transparency was encouraged and staff understood their responsibilities to raise concerns and report and near misses. There were clearly defined and embedded systems, processes and procedures to keep patients safe and safeguarded from abuse.

The SPC teams staffing levels and skill mix were planned, implemented and reviewed to keep patients’ safe. Any staff shortages were responded to quickly and adequately. There were effective handovers and shift changes, to ensure staff could manage risks to patients receiving EoLC.

Patients in receipt of EoLC received effective care and treatment that met their needs. EoLC patients care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. This was monitored to ensure consistency of practice.

The trust’s ‘care of the dying person’ care planning was based on the General Medical Council's (GMC) '5 priorities for end of life care'. The care plan provided comprehensive assessment of patients’ needs. Information about patient’s care and treatment, and their outcomes, was routinely collected and monitored. This information was used to improve EoLC.

There was participation in relevant local and national audits. Outcomes were used to improve patients care and treatment. End of life care patients were supported, treated with dignity and respect, and were involved as partners in their care. Patients and relatives were encouraged to make decisions, and were supported to do so. Staff helped patients and those close to them to cope emotionally with their care and treatment. Patients were supported to maintain and develop their relationships with their families, social networks and community.

Work was in progress for EoLC services to be planned and delivered in a way that met the needs of local people. A steering group had been established in late 2014, and a non-executive director (NED) for EoLC was appointed, but the strategy was recent and not embedded.

The leadership, governance and culture in EoLC services promoted the delivery of person-centred care. There was a clear statement of vision and values for EoLC, driven by quality and safety. The vision, values and strategy had been developed through a structured planning process with regular engagement from internal and external stakeholders at ‘Listening into Action’, (LiA) events, which included patients and staff. EoLC strategic objectives were supported by measurable outcomes, which were cascaded throughout the organisation. The challenges to achieving the strategy, including seven day working, were understood and an action plan was in place.

The board and other levels of governance within the hospital functioned effectively in regards to EoLC. Structures, processes and systems of accountability were clearly set out, understood and effective.

Outpatients

Requires improvement

Updated 7 October 2015

Outpatients and diagnostic imaging were not always safe or well led and required improvement to address this. The service was caring and responsive. There was a gap in leadership at matron level and some staffing shortages both in nurses and administrative staff. There was inconsistency in infection prevention measures and safety checks, with a variance in safeguarding and mandatory training compliance. Some clinic accommodation was inappropriate.

Compliance actions had been set from the previous inspection of the trust in September 2013 in relation to the care and welfare of people in outpatients. The main concerns had been the environment and patient flow through outpatients. There had been physical improvements in main outpatients and the fracture clinic and patient flow had improved. Most of the tasks from the outpatient transformation programme were on schedule. 

There were effective systems for managing referrals, making appointments and collecting data. The hospital was meeting the majority of the national waiting time targets. Patients and staff spoke about delays and waits in outpatients and diagnostic imaging ranging from 30 minutes to over an hour. 

Staff were caring; patients told us that staff always kept them informed and were kind and approachable.

The majority of the performance targets in referral to treatment times were being met. The trust learnt from complaints and sought people’s views on how to improve the experience.

There was a comprehensive plan guiding the improvement and sustainability of outpatients, with systems in place to monitor the performance.