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Croydon University Hospital Requires improvement

We are carrying out checks at Croydon University Hospital. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 21 February 2018

A summary of services at this hospital appears in the overall summary above.

Inspection areas

Safe

Requires improvement

Updated 21 February 2018

Effective

Requires improvement

Updated 21 February 2018

Caring

Good

Updated 21 February 2018

Responsive

Good

Updated 21 February 2018

Well-led

Requires improvement

Updated 21 February 2018

Checks on specific services

Critical care

Requires improvement

Updated 21 February 2018

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

  • There were significant risks associated with the environment, which did not meet Department of Health Health Building Notes. Although the building was in place before these regulations, risks in relation to the environment were often poorly and inconsistently managed.
  • We observed variable levels of adherence to infection prevention and control policies and best practice that placed staff and patients at increased risk.
  • Staff did not effectively or consistently manage fire safety risks.
  • Although staff delivered care and treatment in accordance with national policies and best practice, there was a lack of auditing to monitor outcomes and deliver improvements.
  • Some staff did not demonstrate appropriate knowledge of the Mental Capacity Act (2005), capacity assessments or the implementation of the Deprivation of Liberty Safeguards. This meant patients who experienced fluctuating or reduced capacity to make decisions may not have always received appropriate care.
  • Although there was evidence of multidisciplinary team (MDT) working, this took place on an individual as-needed basis. There were no coordinated MDT meetings even for patients with the most complex needs and members of the MDT team were not included in ward rounds. However, where staff referred a patient we saw the MDT response was timely.
  • Pharmacist cover did not meet the minimum standards of the Intensive Care Society (ICS) and there were gaps in medicines management as a result.
  • There were limited resources available to staff on the unit for patients with needs relating to learning disabilities and dementia and for speakers of languages other than English. Although there was a learning disability lead nurse was in post, staff did not always proactively access resources that were available.
  • Governance and risk management systems were in place but were not always used effectively. There was limited evidence leadership was consistently effective or that it contributed to a sustainable work and care environment.

However:

  • The unit met the requirements of the Faculty of Intensive Care Medicine (FICM) and the (ICS) core standards for intensive care units in relation to staffing levels and competencies.
  • There was an effective system in place for reporting and investigating incidents and evidence that learning was shared in the team.
  • Staff delivered compassionate and attentive care and adapted this to a challenging environment.
  • Staff avoided overnight discharges whenever possible and where these were unavoidable completed an incident report to identify areas for improvement with patient flow.
  • Although we have noted the limited physical resources for staff to help them support patients with a learning disability, a learning disability lead nurse was in post. During our inspection we observed this member of staff provide a high standard of care when a patient was referred to them.

Outpatients and diagnostic imaging

Good

Updated 21 February 2018

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

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

However:

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

Urgent and emergency services

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.

Medical care (including older people’s care)

Requires improvement

Updated 7 October 2015

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 (including older people’s care)

Requires improvement

Updated 28 September 2018

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

  • The service had failed to manage the flow of patients through the service with a large number of outliers and patients being moved at night. This means the trust was not focussed on getting patients a bed on a ward for their speciality
  • Although the medical care core service had taken significant actions to address staff shortages, those actions had, to date, not resulted in improvements in permanent staff numbers.
  • The integrated adult care division risk register had 33 risks identified and we saw evidence that these had been reviewed and updated. Some of the risks had been on the register since 2014. This meant some risks were not being dealt with in a timely way.
  • Most staff in the medical services knew the trust values. However most staff we spoke with were unaware of the integrated medicines divisional strategy.
  • The medical care service was reliant on the use of bank and agency staff to cover gaps in the staffing provision; however due to inconsistencies in the completion of induction sheets the trust could not be assured agency and bank staff were being orientated or inducted onto wards appropriately.
  • Mandatory training in key skills for nursing and medical staff completion rate was 86%. This had improved since the last inspection when the completion rate was 63%. The trust target was 90%.
  • Safeguarding adults level 2 training for medical and nursing staff completion rate was 88%. This had improved since the last inspection when the completion rate was 63%. The trust target of 90%.
  • On the wards we saw evidence of good practice in relation to hand hygiene. However the trusts own internal audit data has identified compliance was variable across the medical wards. Compliance varied from between 100% and 56%.
  • Maintenance on the wards and equipment was not always undertaken in a timely way. For example on one ward found that repairs to windows had been waiting for six months.
  • Appraisals were on a rolling programme with the expectation that all staff would have an appraisal at least once a year. In the last 12 months 77% of registered nurses and 72% of health care assistants had an appraisal which was lower than the trust target of 95%.
  • 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.
  • There was not enough capacity as a result of the flow issues within the hospital to manage the medical patients in the right ward. There were a total of 1442 patients moved at night between 8.00pm and 7.00am between April 2017 and March 2018.
  • A total of 2125 patients were discharged at night between 8.00pm and 7.00am between April 2017 and March 2018 on the medical wards.
  • 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. The integrated adult care division was responsible for the emergency department and all the medical services across the hospital. At a local level they were supported by four clinical business units which had responsibility for specialist, care of the elderly, general and emergency medicine.
  • There were effective structures and process of accountability to support the services within the integrated adult care division. Clinical governance was focused on the quality and safety of care which monitored and reported on infection control, serious incidents, incidents, feedback from friends and family tests, and audits.
  • 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.
  • The trust used electronic patients records (EPR) on the wards. The EPR could only be accessed by staff using a swipe card and password so the system was protected. This meant that patient information and records were stored securely.
  • Patients were being assessed using the Early Warning System. Staff were knowledgeable in responding to any changes in the observations which necessitated the need to escalate the patient to be seen by medical staff or the critical care outreach team.
  • 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 trust 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.
  • Patients prescribed pain relief to be given ‘when required’ were able to request this when they needed it. Patient notes recorded whether patients had been asked about pain.
  • There was effective multidisciplinary team working in the ward areas. Relevant professionals were involved in the assessment, planning and delivery of patient care.
  • Staff had opportunities for further development. Staff could apply for additional training if it was relevant to their role. Practice development educators for supported nursing staff for their revalidation and new nurses in the preceptorship programme.
  • At the last inspection we found mental capacity assessments were not being undertaken when needed and consent was not recorded in patient notes and on this inspection we found this had improved.
  • We saw clinical staff treat people with dignity, respect and kindness during their stay on the wards. Staff were seen to be considerate and empathetic towards patients. Most of the patients we spoke with were positive about the staff that provided their care and treatment.
  • Friends and family test results were displayed on the medical wards. Between May 2017 and May 2018 the trust scored between 87% in April 2018 and 94% in December for recommending the hospital for all inpatient wards. The response rate for inpatient wards over the same period was between 20% in February 2018 and 38% in June 2017.
  • Most patients we spoke with said they felt involved in their care. Most patients knew the name of their consultant and who was in charge of their care.
  • Chaplaincy and counselling services were able to patients who needed them. The hospital had two full time chaplains co-ordinating the provision of 24/7 spiritual and religious care.
  • The care of the elderly wards had been made more dementia friendly. There was matt rather than shiny flooring and use of contrasting colours, large signage with pictures and text for toilets and bathrooms and a sensory room.
  • To expedite weekend discharges patients being considered for discharged consultants would complete a ‘purple form’ on Friday which detailed the criteria for discharge and any pending investigations so that patients could be reviewed and discharged if appropriate.
  • On the care of the elderly wards volunteers assisted staff at meal times and provided shared reading and poetry sessions for patients.

Surgery

Good

Updated 21 February 2018

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

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

However:

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

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

Good

Updated 21 February 2018

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

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

However:

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