Croydon University Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last assessment we rated this key question as requires improvement.

There were concerns regarding the low number of staff who had completed and appraisal and a number of patient outcomes indicators were worse than expected.

At this assessment the rating has remained requires improvement.

We looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. We assessed four quality statements.

Referral to treatment times were still not being met but there had been an improvement and the service was on track to meet the operational standard. However, there were still a number of patients whose length of stay was over the national average and emergency readmission rates had largely stayed the same over a period of time.

Consent was being appropriately applied; however, the documentation and completion of mental capacity assessments was not always being done.

Compliance rates with staff completing an appraisal had improved since the last inspection.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with current evidence-based good practice and standards. They participated in the majority of clinical audits where they were eligible to take part and staff teams worked well together when assessing people’s needs and shared information. There were processes for anyone requiring enhanced support and increased supervision whilst on the ward.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service planned and delivered people's care and treatment with them, including what was important and mattered to them. They did this in line with current evidence-based good practice and standards.

Medical services participated in most of the clinical audits where they were eligible to take part. For example, Baseline assessment tool for cirrhosis in over 16s against national guidance NG50 and stroke rehabilitation in adults NG236.

Patient led assessments of the environment (PLACE) had taken place across the wards. The trust had put in place actions following the results of the PLACE 2024 audit. For example multiple meal options were available and a review of the menu was scheduled of June 2025.

The service had a red tray and red jug system to visually identify patients who needed extra attention or assistance with eating and drinking to ensure they received adequate nutrition and hydration which was in line with evidenced based care. We observed staff ensuring that patients had plenty of drinks throughout the day.

The service monitored the completion of nutrition and hydration risk assessments within 24 hours in line with national guidance. Between May 2024 and March 2025 the compliance rate was above the target of 90%. Screening for the risk of malnutrition in care settings is important for enabling early and effective interventions.

There was a risk of harm from violence and aggression incidents towards ward staff during the course of undertaking their roles. This could be in any form including verbal or physical from patients, staff and visitors. We were told actions from the Violence Prevention and Reduction Standards were being taken forward. A steering group led by the people's directorate met regularly to discuss any further actions.

Audit results were displayed on some wards for staff, patients and the public to be aware of the outcome. For example hand hygiene audits and meeting nutritional needs. However, these were not displayed on all ward areas.

There was an annual audit plan which identified a programme of audits and effectiveness projects. This aligned to national guidance and national quality accounts for example, the national adult diabetes audit, national audit of care at the end of life and the national audit of dementia. The overall monitoring and reporting of all clinical audit activity was led by the quality team supported by directorate level governance.

The service worked well across teams and services to support people.

Nursing handovers took place across the wards. The handovers used both verbal and written communications. Information discussed and shared included, immediate discharge details, those who had a Deprivation of Liberty safeguard as well as any safety incidents.

There were multidisciplinary team meetings daily to discuss patients care plans, which included treatment plans, provisional discharge arrangements and where applicable social circumstances. We observed there was good team working. However we also observed that there was limited focus on estimated discharge dates for each patient.

Ward rounds were led my medical staff. We observed that these were effective with good communication between members of the ward staff. Staff reported good engagement with specialist consultants, and told us that they felt they were treated equally. There appeared to be effective joint working with community teams such as the rapid response team.

There was a good multi-disciplinary approach present across the service areas with examples of joint working across paramedics and community teams in relation to offering training opportunities to the medical same day emergency care team.

There was a dementia lead nurse and enhanced care team support available to ward staff to help with patients who had a longer length of stay due to the social- environmental factors of progressive dementia .Services worked with the Red Cross who helped ensure that food packages were available for those without family support when discharged.

The hospital ambulance team was based in the discharge lounge to help facilitate and co-ordinate the journey home. This was open 24 hours a day but we were told that transfers are normally completed by 5 p.m. and there were no discharges after 8 p.m.

The Trust continued to work closely with partners from the local mental health services to develop the use of the mental health clinical assessment unit (MHCAU). The MHCAU was utilised as a pilot site for a same day emergency care service for individuals experiencing an acute increase in risk of self-harm. The MHCAU staff had received specialist training in delivering interventions in this area.

There was a transfer of care hub which included staff in health and social care roles. This was to manage discharges from hospital. A new management lead commenced in March 2025.

There was access to virtual wards. Virtual wards allow patients to get hospital-level care at home safely and in familiar surroundings, helping speed up their recovery. People were cared for by a multidisciplinary team who provided a range of tests and treatment. However, not all staff we spoke with regarding the virtual ward was aware of its function. Some told us it was to 'keep an eye on them when they got home' or ' for therapy input' or ' a bit of reassurance for patients'. We were told that this may be due to the fact that the team was formally known as the rapid response review team.

There was monitoring being undertaken of the clinical standards for a 7 day service. The trust was meeting the standard of 90% daily consultant review at weekdays but not yet meeting the standard at weekends. However, this was on a upward trajectory and was 79% in October 2024. Actions had been put in place which included a review of job plans and embedding the perfect ward initiatives. The 7 day service is designed to reduced unwarranted variation in outcomes for patients admitted at different times of the week.

There were clear examples of effective processes and collaboration and communication throughout teams. Positive transitions through the critical care outreach team and intensive care nurses. Patients were flagged as part of the pathway of communication between teams, and there was the presence of consistent involvement from the nursing team onwards.

We also saw that in a few of the cases there were delays in being discharged despite discharge plans due to difficulties with suitable packages of care in the community. Staff were working with social care providers to expedite an appropriate placement. However, there were significant delays in their discharge and spending longer in hospital than was needed.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

Whilst the service did routinely monitor people's care and treatment, it did not always ensure that patients who used the service consistently experienced positive outcomes but actions had been identified and there had been some improvements.

Consultant led referral to treatment times monitor the length of time from referral through to elective treatment. The operational standard for the percentage of patients who are waiting less than 18 weeks is 92%. Information showed that the trust had consistently performed better than the national average which was 60% in December 2024. In December 2024, 1.5% of people on the waiting lists were waiting more than 52 weeks which is slightly lower than the national average of 2.5%. However, recent national information published states that by March 2026 the intention is that the standard will be 65% and meeting the standard of 92% by March 2029.

The trusts daily percentage of occupied beds which have been occupied by a patient with a 7+ day length of stay has risen. Over winter 2023/24 the percentage was slightly higher than England's, with an overall percentage of 49% compared to 47%. However, in winter 2024/25, while England's overall percentage has remained at 47%, the trust has risen to 55%.

The average length of stay for emergency admissions was on the third quartile nationally. For example in August 2024 the average length of stay was 11.2 days compared to the national average of 10.4 days. The highest length of stay appeared to be on the geriatric medicine and care of the elderly wards as well as the stroke unit.

The NHS standard is that 85% of people with cancer should begin their treatment within 31 days of a decision to treat their cancer. The trust's performance has fluctuated over time, though recently, since July 2024, it had achieved the NHS standard.

The NHS standard is that at least 75% of people should have cancer ruled out or receive a diagnosis within 28 days of an urgent cancer referral from their GP. Between December 2022 and February 2024, the trust improved its performance from 52% to 88%. Though performance had fallen over 2024 to 80%, this was still better than the NHS standard and is slightly above the national and regional averages.

The percentage of emergency admissions with a length of stay over 20 days was 9.7% in November 2024. Between January 2024 and November 2024 this had been over 9% consistently but was on a downward trajectory from the previous year.

Readmission information showed that although rates were about the same as the national average, apart from acute bronchitis, overtime these rates had largely stayed the same and had not improved.

The sentinel stroke national audit programme (SSNAP) is a programme of work that aims to improve the quality of stroke care by auditing stroke services against evidence-based standards. The latest audit results rated the hospital overall as a grade `C' which was the same as previous audit results between April 2024 and September 2024. The scores are between A and E. Overall performance was in the middle band, but performance was in the worst band in a couple of domains. There was a plan to improve performance, for example, recruitment processes for therapy staff, a review of the care pathway and looking at community services capacity to help reduce the length of stay.

The service took part in the adult inpatient survey 2023. This survey looks at the experience of people who stayed at least one night in hospital as an inpatient. The hospital performed worse than expected in 4 of the domains. A common theme was lack of patient involvement in care.

The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators which is used to measure mortality outcomes at trust level across the NHS in England using a standard and transparent methodology. The risk score is the ratio between the actual and expected number of adverse outcomes. A score of 100 would mean that the number of adverse outcomes is as expected compared to England. Between November 2023 and October 2024 the score was 1.06. Work continued to better understand the recent changes in the mortality indices including SHMI. We were told that the increase in the SHMI score was more likely to be due to changes in coding and calculations, then due to sub-optimal care.

Last year the service undertook an baseline assessment of all the wards as part of the newly launched nursing ward accreditation programme. The accreditation framework included communication and information, mouth care, nutrition and supporting mobility.

The endoscope decontamination unit was managed by the decontamination services manager. The department had systems and processes that met the requirements of the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accreditation. All equipment within the Endoscope Decontamination Unit have had their quarterly and annual testing completed and passed all criteria.

The service did not always ensure that staff applied the Mental Capacity Act in line with legislation, although consent was appropriately applied when delivering care and treatment.

Information between April 2024 and April 2025 showed that compliance with undertaking a mental capacity assessment by a nurse for dementia, delirium and confusion across the elderly wards ranged between 82% and 90%. Across other medical wards this was over 90% for the majority of the months audited. However, compliance for `if appropriate does the patient have a documented mental capacity assessment' in March 2025 was 87% and in April 2025 this was down to 37%.

There was a Mental Capacity Act and Deprivation of Liberty safeguards policy. This also outlined that all new staff should have Mental Capacity Act Level 1 training and clinical staff must attend the appropriate level of safeguarding and Mental Capacity Act/Deprivation of Liberty Safeguards training to enable them to carry out their duties. From information we received we found that Mental Capacity Act and Deprivation of Liberty safeguards training is part of Level 3 safeguarding training. However, compliance with safeguarding training for medical staff, who would complete a documented mental capacity assessments was below the trust target. This was 70% and 66%.

The trust had acknowledged that improvement was required to ensure compliance with the Mental Capacity Act 2005 and a quality improvement project had been undertaken. The outcome of this was that there had been an increase in the percentage of both mental capacity assessment and the number of deprivation of Liberty Safeguards applications made where required but was still below the trust target of 90% at 69%. This related to only 3 wards that were audited. The trust had put in further actions for 2025 which included standalone interactive Mental Capacity Act training.

Medical staff told us that they completed formal capacity assessments when required. Some staff we spoke with did get confused with mental capacity assessments and enhanced care assessments which were completed by the enhanced care team and were for patients with more complex needs and increased observation needs. These were not formal mental capacity assessments.

We found two examples of patients who were recorded as not having capacity but no capacity assessment or record of best interest assessment taken place. We raised this with staff who immediately put in place the process of review of the patient's capacity. We reviewed 8 records of those who required a mental capacity assessment meaning that 25% did not have a documented capacity assessment when required.

However, on review of the mental capacity assessments that had been completed we saw appropriate discussion with patients and their families had taken place.

Mental capacity assessments are important because they determine a person's ability to make decisions for themselves, and protect their rights. The assessments also guide decisions about care and treatment, ensuring they are made in the person's best interests when they are unable to make them themselves.

Services were now beginning to use electronic consent forms instead of paper-based forms. At the time of the assessment this was being rolled out to surgical services as a pilot before rolling out to other services. The aim was to provide a better patient experience as well as improved understanding of the decision making process. It was hoped that this would also minimise the change of needing to cancel a procedure on the day due to issues with consent. This would also be available to view in multiple languages. We saw evidence of staff seeking consent to undertake procedures and care.

There was a policy to support staff in the implementation of resuscitation and do not attempt cardiopulmonary resuscitation(DNACPR). We asked for evidence that DNACPR was being implemented in line with policy and we were provided with a presentation of an audit that was completed in 2023. However, we did not receive any evidence that this was monitored on an ongoing basis. This meant there was a risk that staff may be acting outside of a patient's wishes or best interests in situations that require cardiopulmonary resuscitation due to poor governance and oversight of this process.

Wards used the London Care Record to record patients resuscitation status. The London Care Record is used by health and care professions across London involved in a patients care. If appropriate when a patient was discharged a paper do not attempt cardiopulmonary resuscitation form was used on transferring the patient from hospital to be shared with other professionals. For example the ambulance service.

There was in place a reducing the need for restrictive interventions across the hospital. This was to provide guidance in the use of restraint and restrictive practice. The policy stated that specific staff should have restraint reduction training and all staff must complete conflict resolution training. On reviewing the conflict resolution training for the elderly wards the compliance rate for medical staff was 68.3%, for nursing staff and healthcare workers this was above the trust target of 90%. Training compliance for medical staff on the medical wards was 62.5% and for nursing staff and healthcare support workers on the medical wards this was above the trust target of 90%.

Nursing staff and senior management staff were clear about the procedures to follow when reaching decisions about using bed rails which are a form of restraint.

We were told there was an enhanced care team for anyone requiring enhanced support and increased supervision. This could be for those living with dementia of for those with a mental health illness. The enhanced care team worked closely with the ward teams for example when patients were having times of agitation. The approach followed the least restrictive practice.