Croydon University Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

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

We highlighted concerns regarding mandatory training compliance not meeting the trust target.

At this assessment the rating has remained requires improvement.

We looked for evidence that people were protected from abuse and avoidable harm. We assessed eight quality statements.

Incidents were reported by staff through systems and whilst staff were aware of lessons learnt and improvement from investigations directly involving the area they worked; staff did not always receive feedback on learning from other areas. Senior leaders were aware that this was not being monitored effectively. There did not appear to be an effective system to confirm that Duty of Candour was being applied where appropriate.

There were systems in place to keep people safe and staff were aware of how to ensure patients were safeguarded from abuse, however compliance rates for staff completing the required training was low in some areas.

Whilst there were some good safe systems and processes in place, we found that the recording of discharge plans from admission was not always completed in patient records. We also found that the number of observations that required increased frequency were not being completed in a timely manner to help manage the risk to patients who maybe deteriorating.

We found cleaning chemicals and consumables which could be harmful to patients and the public left in unlocked areas which were unattended. We also found it difficult to find wards and services in the hospital due to incorrect signage.

There were systems in place to manage the safe administration and prescribing of medication, though there were areas where there needed to be improvement. Staff attended mandatory and required training courses but compliance rates for some subjects were still below the trust target, especially for medical staff.

The service did not always make sure that there were enough skilled and experienced staff on the wards and at times the skill mix was not in line with national guidance.

Clinical risk assessments were being completed in line with trust and national guidance to help identify patients at high risk of harm. The hospital was overall visibly clean and staff followed good infection, prevention and control standards.

We have not awarded this service a score for Safe.

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

Whilst the service was working to embed a culture of safety and continuous improvement, learning from events and incidents that had either put people and staff at risk of harm, or that had caused them harm, there were systems that were not fully effective to ensure that they were being open and honest following incidents.

There were structured processes in place for incident reporting. In line with national guidance, the service moved on to the new Patient Safety Incident Response framework in July 2023. As part of this, the trust has a clear Patient Safety Incident Response Plan (PSIRP) which outlined the identified patient safety risk profile for the organisation and focused on their improvement approach. Staff reported incidents via the electronic incident reporting system.

We were told learning from incidents was cascaded to staff either through meetings or safety huddles. However, on reviewing the clinical governance meetings incidents were discussed but limited evidence of action to cascade this further. The trust had recognised that shared learning was difficult to monitor so were looking at developing actions plans in learning reviews. However, these were not fully in place at the time of the assessment for us to assess the effectiveness.

Some of the staff we spoke with could outline examples of learning that had been cascaded, for example learning from a medication and how processes had been amended to manage the risk in their particular work area.

However, whilst staff we spoke with could tell us about the process for reporting incidents and felt confident to raise concerns and report incidents and received feedback and learning relevant to their area of work, some staff told us they did not always receive feedback on learning from other areas.

We reviewed the number of incidents being reported and found that over a 12 month period there had been a decrease in reporting compared to the previous year. Good incident reporting is vital for identifying and preventing future occurrences and improve safety. Overall in the organisation, for which medical services were part of, there had been an 8.2% decrease in reporting compared to the previous year. The wider trust team were working with staff in medical services to improve incident reporting.

There was a directorate wide `make a difference forum' held weekly which included shared learning from incidents with external partners.

All in-patient deaths were reviewed by a consultant within an expected timeframe, with learning from mortality review discussed at governance meetings and there was a report on learning from mortality reviews. There was also an established team of medical examiners who carried out a review of deaths that occurred in the hospital to help identify any learning.

Senior staff were aware of their responsibilities relating to Duty of Candour legislation. The trust had a Duty of Candour process in place to ensure that people had been appropriately informed of an incident and the actions that had been taken to prevent recurrence. The aim of the Duty of Candour regulation is to ensure trusts are open and transparent with people who use services and inform and apologise to them when things go wrong with their care and treatment.

Also staff we spoke with, at different levels, were aware of their responsibilities relating to Duty of Candour (DoC).

However, out of the 278 incidents on medical wards we reviewed only 3 had DoC recorded as applied. In elderly services out of 126 only 4 had DoC recorded as applied. On reviewing the information recorded in the incidents there were occasions when there were incidents that potentially met the requirements for DoC to be applied.

Senior staff in the trust we spoke with told us that due to a change in systems, there was possibly an error with the way information around DoC was being recorded. Therefore, we cannot be assured that DoC was always being applied when required and the system effectively able to confirm this.

Patients and those close to them knew how to raise concerns or make a complaint. We reviewed a number of complaints and saw that learning had taken place and actions put in place.

There was a Patient Advice and Liaison Services (PALS) which offered free and confidential help for patients who had a query or concerns about their treatment and care provided by the service. They used the feedback to help improve services.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored in the majority of cases; However some systems were less effective especially around discharge processes to ensure continuity of care.

There were pathways into services provided by medical care, for example frailty same day emergency care and medical same day emergency care (SDEC). These included referrals directly from the emergency department, community services such as the rapid response team, 111 or the ambulance services. There were a set of criteria for staff to follow to ensure that patients were referred appropriately and safely.

However we had concerns regarding some of the systems and processes. Both medical SDEC and frailty SDEC were only open during the day and if patients were waiting for a bed from the unit after a decision to admit and a bed was not yet available, they were transferred to the emergency department to wait for a bed. This meant that an already full emergency department had additional patients to care for and was not the most appropriate environment to meet the patient's individual needs.

The trust had in place an electronic patient record that all services used. The clinical notes operate as a summary contemporaneous record and some elements of nursing care were still recorded on paper.

The records we reviewed included all multi-disciplinary team staff involved in the patients care. Care plans had been put in place in the majority of cases, apart from some that did not have a care plans following a risk assessment highlighting them as at high risk of falls. Information between April 2024 and April 2025 showed that compliance with a falls management plan being in place was 100% across the elderly wards. However, we did not see any evidence that this was audited for other medical wards.

On reviewing patient records it was not apparent that discharge planning was being discussed or plans recorded from the point of admission for all patients. Out of the 14 records reviewed to look at discharge plans, 7 did not have any record of any discharge plans in place. This is important as from the onset of a patient's admission there needs to be a clear expectation of what is going to happen to help reduce unnecessary waits in hospital.

Email is widely accepted as the primary communication tool used every day by all levels of staff in organisations. They often contain business and clinical information that is not captured elsewhere and so need to be managed just like other record. A number of records we reviewed mentioned there had been a referral to the enhanced care team but there was not a copy of the referral retained electronically in the patient's electronic record. We were told that these were stored on the enhanced care team email account for each year. We are not assured that relevant clinical information was being retained in line with national guidance.

The service undertook regular medical records and documentation audits. For example if sets of observations had been completed and escalated where needed, and if pain scores had been recorded. Information between April 2024 and April 2025 showed that in a large number of areas compliance was above 90%. However, we were not provided with any evidence that areas where compliance was low actions had been put in place.

Frailty SDEC was a new service which consisted of advanced nurse practitioners and advanced care practitioners with a range of skills and experience, for example, occupational therapy and physiotherapy. They also had access to an elderly care consultant. Staff in reached into the emergency department to move appropriate patients into the frailty unit to undertake a comprehensive geriatric assessment. There was an inclusion and exclusion criteria. The aim was to discharge the same day with a package of care in place that met the needs of the individual patient. We found that the team was highly motivated, and keen to move the service forward. At the time of the assessment, the team was only able to see around six patients a day. The team aimed to start more in reach into wards to help support patients.

Medical SDEC had a multidisciplinary team of nurses, medical staff including a dedicated registrar for the unit and a daily consultant. There were also advanced nurse practitioners available.

At the time of the inspection, there was a standard operating procedure for the clinical and operational management of the acute medical unit. This outlined the role and function of the unit and provided clarity on pathways and access criteria. The acute medical unit provided assessment, investigation and treatment for acutely unwell patients. This procedure had recently been relaunched as part of the hospital programme of improving flow through care pathways as it was found that patients were spending longer on the unit than needed.

As part of this programme there was a plan in place to turn a bay of the acute medical unit into a medical decision unit housing 6 to 8 chairs to ease flow from the emergency department on a trial basis.

Patients typically stay in an acute medical unit for a short period, usually 24 to 48 hours as they are designed for initial assessment, stabilisation and urgent investigations before patients are either discharged or transferred to a speciality ward for further care. However, the hospital had taken the decision that patients could stay in the unit for up to 4 days before fully considering next steps in their journey of care. We were told this was due to the number of monitored beds available which meant that these patients would normally have a longer length of stay on the unit as they did not want to move them unnecessarily.

The acute medical unit has a specific bay with 14 beds available which was used for patients that were unwell and needed more intensive level of care. These bays had advanced monitoring equipment to ensure timely detection and management of any changes in a patient's condition. Staff had received additional training to safely care for these patients and due to the acuity there were times when additional staff was available. An AMU consultant was on call between 8.30 am to 8.30 pm on weekdays and 8am to 2 pm at weekends.

When patients arrived at the medical SDEC they reported to reception and a nurse triaged the patient within 15 minutes and completed a set of observations. We were told that they were over 60% compliance on average, and there had been numerous times when they had been 90% compliant with this target. We were also told that there was a 6 hour in the department to discharge target in place and on average patients were in the unit between 4 to 6 hours. Patients were to be seen by a consultant within 2 hours but the average time was within 1 hour.

The falls service worked within a multidisciplinary team which included elderly care physicians, physiotherapist and occupational therapists depending on patients' individual needs.

The rapid assessment medical unit(RAMU) was an assessment area where patients were first reviewed by a junior doctor and then a consultant. Patients were then either discharged home or admitted to the acute medical unit. If after assessment it was likely that the patient would need a longer stay they would be transferred to a medical ward.

There was an acute care of the elderly unit(ACE unit) which was a consultant led service which offered comprehensive and focused multidisciplinary support for patients over the age of 80 years

There were multidisciplinary teams in place which included medical staff, nurses, dedicated pharmacists and therapy staff. Consultant led ward rounds took place. twice a day in the week and once a day, in the morning, at weekends and bank holidays and a review of patient records confirmed this. This was to help ensure that patients were reviewed early and discharged either to home, further community care or transferred to an appropriate ward.

Environmental risk assessments were completed across the wards, for example on the wards a risk assessments were undertaken to assess the risk of additional bed spaces on wards at time of escalation and the impact on patient care and experience.

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There was a strong understanding of safeguarding and how to take appropriate action. However, we were not fully assured that medical staff were supported to understand safeguarding at the correct level to keep patients safe from abuse and neglect.

There were safeguarding policies and procedures and staff knew how to refer a safeguarding issue to protect adults and children from abuse. The trust had a safeguarding team which provided guidance and staff had access to advice out of hours and at weekends. The policies contained relevant contact details for raising a safeguarding concern. There was an aligned safeguarding advisor on pilot wards to help support staff with the completion of safeguarding referrals, Mental Capacity Act assessments and Deprivation of Liberty safeguards. There was also a domestic abuse advocate available as support.

There was a management of domestic abuse and sexual violence policy and a PREVENT policy to support staff.

Staff undertook Prevent training and compliance in elderly care services was above the trust target for nursing staff and healthcare assistants but at 67% for doctors. Across the medical wards it was 63.4 for medical staff and above the trust target for nursing and healthcare support workers. Prevent is a national programme that aims to stop people from becoming terrorists or supporting terrorism.

Staff undertook safeguarding training that was in line with national guidance, though it was below the trust target for some staff groups. As of February 2025 the compliance rate for doctors working on the elderly wards for safeguarding adults was 70.7% and for safeguarding children this was just below 70%. For nursing staff working on the elderly wards this was 97% and 96% retrospectively. Compliance rates for the medical staff on the medical wards was 66.1% for safeguarding adults and 51.8% for safeguarding children. Compliance rates for nursing staff on the medical wards was 54.9 % for safeguarding children and above the trust target for safeguarding adults as was the compliance rates for healthcare support workers for both safeguarding adults and children.

Some staff we spoke with told us that their safeguarding training was some time ago and could not remember exactly when they had received this training.

The trust policy for the rainbow children’s unit stated that young people over the age of 16 will be admitted to adult inpatient wards but advice was available for staff from the children's services. There was no information in the policy to indicate if a safeguarding review would be undertaken to ensure that they were not at risk of harm. The legal age of majority is 18 years of age.

Staff had access to the mental health team 24 hours a day to support them and patients. We were told the team were responsive and supportive but there could be significant delays getting input for patients in ward areas.

Staff had knowledge and understanding of procedures relating to the Deprivation of Liberty Safeguards (DoLS) which are part of the Mental Capacity Act 2005. They aimed to make sure that people in hospital were looked after in a way that did not inappropriately restrict their freedom. This included people who may lack capacity. We saw examples of DoLS paperwork mostly completed fully and accurately.

However this was not consistently applied and we found two records where processes had not been completed fully. We raised this with staff who completed the relevant safeguarding referrals and DoLS applications.

Management of the risk to the deteriorating patient was not always in line with guidance and patients were not always assessed and their safety monitored and managed, so they were supported to stay safe. There had been improvement is some risk assessments being completed.

On admission staff carried out risk assessments to identify patients at risk of harm. Patients at high risk were placed on care pathways and care plans to ensure they received the right level of care. The risk assessments included falls, pressure ulcer and nutrition. We reviewed care records and observed that risk assessments for these areas had been completed. However, there were occasions when we did not see a care plan for patients who were at high risk of falls following the assessment. The service monitored the completion of risk assessments.

In line with National Institute for Health and Care Excellence (NICE) guidance, all patients should be risk assessed on admission to hospital for venous thromboembolism(VTE). On review of information provided by the trust we found that compliance levels across medical wards was over the trust and national target of 95% over a 12 month period. When we reviewed patients notes we also found that these were being completed in line with guidance.

The National Early Warning Score 2 tool (NEWS2) was used throughout the trust to alert staff if a patient's condition was deteriorating. This was a basic set of observations such as respiratory rate, temperature, blood pressure and pain score used to alert staff to any changes in a patient's condition. There was guidance for staff to follow to help inform what to do if a patient's condition was deteriorating. There was a critical care outreach team who provided support for patients whose NEWS2 was above a certain level. Staff we spoke with knew how to contact this team.

The service was aware that the central monitoring hub, which monitored patient deterioration was not working effectively as there was a system failure to alert when the vital signs were out of range. This reduced the ability of timely action to call for help when needed. This was on the corporate risk register and one of the actions was for staff to check patients on a regular basis, every 30 minutes, and a new service provider was due to be in place by June 2025.

From audit information there had been an improving trajectory from 83% to 89% of observations being taken on time between April 2024 and December 2024 when looked at as an overall.

However, there had been a downward trajectory for the number of observations that required increased frequency with a score of 5 and above, between September 2024 and December 2024. Also, the number of observations completed on time had improved initially but in August 2024 this plateaued at 82% and then on a downward trajectory in December 2024.

On reviewing the most recent data for January 2025 and February 2025, there appeared to be a low percentage of repeat observations being completed within agreed times the higher the NEWS2 score was, which is of concern as this meant there was a risk that patients may not be responded to in a timely way should they deteriorate further. The information showed that this ranged between 10% and 64% for NEWS2 scores 4 and above across the medical and elderly wards.

The response by the critical care outreach team was also monitored to ensure they responded within 30 minutes. Overall this has been on an upward trajectory between April 2024 and December 2024 with one month showing a drop. Latterly, the percentage of calls responded to in 30 minutes was above 92%.

The trust provided training on the deteriorating patient through external and internal courses. From information we reviewed across medical and elderly care wards, 44 staff completed an external course and 66 an internal course. New staff would also complete their induction which included information on taking observations. However, from the information it was unclear what grade of staff had completed this training and how many staff needed to complete this training.

The trust care of the deteriorating adult inpatient policy stated that the training for nursing and medical staff should be to complete the online training provided by the Royal College of Physicians and the policy will be part of the training for BLS and ILS mandatory sessions. It did not state any training for healthcare support workers. The resuscitation training levels for nursing staff were around the target of 90% but well below the trust target for medical staff.

Staff with spoke with also told us that the critical care outreach team provided acutely unwell courses once a month. However, this was not mandatory and just for nurses at present. Staff also told us that they had bedside teaching, however some staff were unable to tell us the correct response required for various NEWS2 scores but the majority were able to outline the process.

There was a recent review of the recognition and escalation of the deteriorating patient to identify any new opportunities for learning and improvement. There were some areas of improvement identified as well as actions to take. For example to make changes to the electronic system when observations were entered and a nurse in charge was required to be informed, this would automatically prompt staff to inform the nurse in charge and for them to record that this had been done. The trust told us that they had put in place further actions which included the ward leader conducting a spot check regarding compliance.

However, these were not fully implemented at the time of the assessment for us to assess the effectiveness.

There was an initiative run by the critical care outreach team as part of national guidance and Martha's rule. Patients or loved ones could call a 24-hour helpline with concerns about themselves or relatives who they felt were deteriorating. Relatives were often able to more quickly identify if there was something wrong with a person they loved than staff, so this was a mechanism by which they could enhance care. People were encouraged to speak to medical and nursing team on the ward prior to calling the helpline for advice but the initiative provided a mechanism for people who were concerned about themselves or a patient to escalate this.

The service did not always detect and control potential risks in the care environment and make sure equipment and facilities supported the delivery of safe care and always meet patient needs.

In order to maintain the security of patients, visitors were required to use the intercom system outside wards to identify themselves on arrival before they were able to access the ward and staff had access codes.

Each clinical area had resuscitation equipment readily available. There were systems to ensure it was checked and ready for use on a daily basis. Records indicated that daily checks of the equipment had taken place on the wards we visited.

Oxygen was secured in line with Health and Safety best practice guidance.

However, we observed a trolley on the acute medical unit with consumables to take blood samples opposite the nurses station but also accessible to patients and the public which was unlocked and contained needles and cannulas. This was a risk to the safety of the patients and members of the public.

We found on the acute care of the elderly ward substances that were subject to Control of Substances Hazardous to Health Regulations (COSHH) which should be stored securely due to the risk of harm to people were stored in an unlocked sluice room. Following the assessment evidence showed that all staff had been reminded to keep COSHH substances in line with guidance.

On medical same day emergency care unit (SDEC) found the clean utility room unlocked and some cupboards unlocked which contained consumables which posed a risk to patients and the public. For example IV fluids, cannulas, and needles as well as medication left on the side. We raised this with staff who immediately secured the cupboards and utility room.

On the acute medical unit we found there were piped air connection points in ward rooms which weren't capped as required by the 2021 National Patient Safety Alerts (NPSA).

Sharps containers should be kept in a secure location, inaccessible to children and the public. Wall-mounted sharps bins should be kept closed when not in use. We observed wall mounted sharp boxes next to patient chairs which were not temporarily closed and also a portable sharp box open and accessible to the public in an open room on medical SDEC. Both contained used sharps, such as needles. We raised this with staff who immediately made sure they were temporarily closed.

The entrance to SDEC was not well sign posted, he environment was busy, with cramped chairs in the waiting room. There was little space for confidential conversations which the team were conscious of.

There were a number of ward areas that had moved location recently but not all the signage had been amended. Patients and the public told us that they had spent quite a bit of time walking around trying to find where they should be. We also found this at times difficult during our assessment.

We also found that signage on some of the ward areas was confusing as their function and role had recently changed but the signage remained the same. For example, the ward areas labelled as 'HDU' as well as 'Critical Care Unit' was confusing for 2 reasons — the adjacent ward was called `Coronary Care Unit' which was also abbreviated to `CCU', and the HDU was not in fact HDU but an escalation bay. This may cause issues for patients and relatives, but also staff who may not be able to find the right place in an emergency.

The service did not always make sure there were enough skilled and experienced staff at all times on the wards. They did not always make sure staff received effective support, and development.

The service had a `safe care' tool with a red flag system that was used to identify areas in most need of staffing on a daily basis in line with patient numbers, acuity, and dependency. From this information staff were redistributed to the wards where additional patient care was needed. However, the trust was aware that work was still needed to embed the'safe care' tool across all services.

Care hours per patient day is a measure of workforce deployment that can be used at ward level. It takes account of the acuity and dependency of patients on the ward. Between December 2023 and October 2024 the trust was amongst the lowest in the region. However, in March 2025 it was 8.46 and the national median was 8.6 and was in the middle 50% of acute trust nationally.

During the day all medical wards had a registered nurse to patient ratio of 1:6 against a national average of 1:8. Between December 2023 and October 2024 the average fill rate for registered nursing staff was 94%.

In the last 3 months there had only been 2 incidents reported relating to lack of staff available across medical services and there had been no red flag incidents reported.

There were adequate nurse staffing levels on the wards at the time of the assessment. There were meetings during the day to discuss staffing levels on the wards and there was an escalation process for staff to escalate any staffing issues.

Between January 2024 and December 2024, staff turnover and leavers across the trust was on a downward trajectory. However, the rate of medical staff leaving the trust has increased over the past 4 years, from around 5% in 2021 and 10% in 2024.

Senior leaders told us that there was a positive approach to recruitment which had improved capacity.

Medical staff we spoke with told us that there were gaps in rotas due to the low number of registrars at the hospital, however they were aware that there were plans to recruit further medical staff. On reviewing the medical rotas, doctors were allocated shifts and on-call arrangements. These were planned in advance

While the service planned and managed staffing in line with national guidance where applicable and considered the use of bank staff when staffing levels fell below these requirements, we had concerns regarding the skill mix on wards.

The optimal staffing skill mix on medical wards involves a balance of registered nurses and healthcare assistants to ensure safe and effective patient care. national institute for health and care guidance (NICE) recommends that skill mix should be between 60:40 and 70:30. Royal College of Nursing guidance recommends a ratio would be around 65% registered nurses to 35% health care assistants. Ward staffing reviews should be done biannually as a minimum according to the principals.

From information we reviewed across the trust this had varied from 53% registered nurses to 47% healthcare assistants on a day shift with night and weekend shifts frequently having a more diluted skill mix of 50% registered nurses and 50% healthcare assistants.

There was a safe nursing staff escalation policy for medical wards (2022 to 2025). This outlined the set establishment for nursing and healthcare assistants across the wards. On review of the establishment there were a number of medical and elderly wards where the skill mix was set at 50%. At night there were 7 wards out of 14 where the skill mix was set at 50% and 8 out of 14 at weekends.

The policy stated there should be bi-annual reports to trust board. In November 2024 the board received the highlights of the staffing report that went to the quality committee not the actual report. No action was outlined in the summary report to the board to increase or review skill mix in establishments or the reason why. In the minutes of the November meeting it stated `The Chair of the Quality Committee's report was received for information without comment.' Therefore we could not be assured that the skill mix on wards was being adequately monitored by senior leaders and actions identified to ensure it was safe.

All providers of care services are required to ensure all staff have received training in how to support people with a learning disability and autistic people if they do or are likely to have contact with them. Staff in medical care services received appropriate training at tier 1. However, there was still some staff who were required to complete tier 2 training.

Staff received core training and required learning on a rolling programme in areas such as infection control, manual handling and fire. We did not see any evidence that medicines management was included as required learning. At the time of our assessment the compliance rate across all areas for medical staff on the elderly wards was below the trust target with an overall compliance rate of 60.6%. The lowest compliance was in resuscitation which was at 34%. For nursing staff across the elderly wards the overall compliance rate was above the trust target at 92.8% and for healthcare workers it was 90.5%.

At the time of our assessment the compliance rate across all areas for medical staff on the medical wards was below the trust target with an overall compliance rate of 54%. The lowest compliance was in resuscitation which was at 26.2%. For nursing staff across the medical ward the overall compliance rate was just below the trust target at 87.2% and for healthcare workers it was 85.5%. The trust target was 90%

Staff told us that they had been supported through good induction and training processes when commencing working at the hospital and on the wards. The majority of staff could tell us about what mandatory training they had recently completed.

Staff told us they received an annual appraisal. According to trust figures at the time of the assessment only 76.5% of doctors in medical care services had received an annual appraisal 93% of staff in medical care services had received their annual appraisal, 93.1% of registered nurses and 87.3% of healthcare support workers had received their annual appraisal.

Staff were aware of the guardian of safe working and how to contact them. The Guardian of Safe Working Hours is an independent role designed to ensure junior doctors and patients are protected from unsafe working conditions and hours.

We were told by staff that supervision was available from the matron and ward manager, but there was no set structure to the supervision sessions.

The service assessed and managed the risk of infection. Patients were always being protected as much as possible from the risk of infection.

Standards of cleanliness and hygiene were the majority of times maintained. Monthly infection, prevention and control (IPC) audits were undertaken across all wards which looked at standards such as cleanliness of commodes and hand hygiene. We looked at the results of these audits which showed that hand hygiene compliance was above 90% across the wards and compliance with the use of personal protective equipment was also above 90%.

We were told that increased incidents of infection or poor compliance with standards the IPC team completed additional audits. Patients in healthcare settings are at risk of getting infections while receiving treatment for other conditions. Hand hygiene can prevent the spread of germs, including those that are resistant to antibiotics, and protect healthcare staff and patients.

There was an infection control taskforce and committee that reviewed outcomes of audits and any hospital acquired infections to demonstrate areas of good practice and areas of concern and any actions identified.

There was personal protective equipment available and we observed staff using these. Staff complied with bare below elbows in accordance with national institute for health and care excellence (NICE) guidance. There were handwashing facilities available as well as hand sanitiser at the entrance to wards and by patients beds.

There was training available for staff on infection, prevention and control. At the time of the assessment compliance rates for registered nurses and healthcare support workers across the elderly wards and medical wards was near or meeting the trust target of 90%. However, compliance for medical staff was low. On the elderly wards it was 57.1% and on the medical wards it was 53.3%.

There were link infection control nurses available on ward areas to help ensure standards of cleanliness and hygiene were always maintained.

Cleaning schedules and clean audits were also undertaken. For example if patient equipment was clean and if the environment was visibly clean and in a good state of repair.

Cleaning services for the wards was provided by an external contractor who completed regular audits to check cleaning standards. In addition the facilities management staff and infection control staff also audited cleaning standards.

During the reporting period of 2023-2024, the total number of hospital onset Clostridioides difficile cases recorded was 24 against a trajectory of 19. For MRSA Bacteraemia, 3 cases were recorded against the zero tolerance target for the Trust. Root cause analyses were carried out on all healthcare associated cases.

Patient areas were visibly clean and odour free. We observed cleaners across all wards we visited, cleaning the environment. Patient led assessments of the environment (PLACE) in 2024 showed a standard of 98% for cleanliness at the hospital and 96% for condition appearance and maintenance.

Patients with infections were cared for in side rooms and we observed signs indicating infections on the doors and the doors kept closed to help reduce the spread of infections to other patients.

There were policies and procedures available to support staff in the prevention and control of infections. These included Aseptic Non-Touch Technique (ANTT), infection Prevention and Control Policy and Tuberculosis Policy.

The service made sure that medicines and treatments were safe in most case and met people's needs, capacities and preferences. However, there were areas of medicines management that needed to improve.

Medicines were stored in secure storage areas with access restricted to authorised staff in the majority of cases and these areas were kept clean and clutter free. Medicines were generally stored in line with the national guidance, however, on Wandle 3 we found various small volume injection solutions were decanted from their original outer packaging and mixed in open containers. This was not in line with trust policy. This meant there was an increased risk of mis selection. We also saw medicines that were being returned to pharmacy were not always stored securely in line with national guidance.

Medicines that were no longer required or expired including unwanted "to take away" medications (TTAs) were not always returned to pharmacy in a timely manner. We saw on multiple wards, TTA medicines were being stored for patients no longer on the wards. For example, on Wandle 1 ward there were two bags of TTA medicines for patients who had left the ward the month prior. Staff told us that these were not given as there had been last minute changes to the prescriptions.

Controlled drugs (CDs) were stored securely. However, Controlled drugs that had expired where not clearly segregated from in use stock. Furthermore, we found controlled drugs that had expired in September 2024 in the CD cupboard on Wandle 3. There was a risk that expired medicines could be administered to patients.

Controlled drugs registers were not always completed in line with legislation. Whilst we saw no evidence of discrepancies, there were instances where multiple CDs were recorded on the same page and were not completed in a way to avoid alteration on multiple wards. CD registers should have separate sections for each class of CD and within this each formulation and strength should be recorded on a separate page.

Medicines were always generally given as prescribed. From records we reviewed on the day of inspection, we did not see inappropriate missed doses of medicines and when medicines were given, they were given on time. However, data provided by the trust following the assessment showed that most wards did not meet the trust target for the administration of people's medicines. Whilst there had been some improvement since January 2025, in March 2025 there had been a downward trajectory with 13 wards out of 14 not meeting the target of less than 1% total inappropriate missed doses with an average across all wards of 2.2%. This included medicines that were deemed high risk. Leaders told us that this was partly because of the limitations of the data produced by administration systems. This performance was regularly discussed at medicines safety meetings, and we saw actions were being taken to improve performance including improving data systems and training for staff.

Staff on the wards were supported by pharmacists and pharmacy technicians for clinical queries, stock management and reconciling people's medicines on admission. Staff spoke highly of the support, and we evidence of positive clinical interventions and multi-disciplinary team working.

Whilst pharmacy staff worked to prioritise reviewing patients on high risk medicines such as medicines for thinning the blood, medicines for Parkinson's and insulin, the support was limited due to vacancies. From data provided by the trust peoples medicines were not always reconciled in line with national guidance when admitted to the hospital. Trust wide data showed in March 2025, that only 38% of patients had their medicines reconciled within 24 hours of being admitted. Medicines should be reconciled within 24 hours to reduce the risk of medicine related errors.

Medicines for people on discharge were supplied in a timely way and the service worked well to identify areas that could be improved. Pharmacy regularly met the trust targets for the timely supply of discharge medicines (TTA)to medical wards. Initiatives that supported this included use of the satellite pharmacy based on the wards and training pharmacists to transcribe TTA prescriptions. This has led to decrease in time taken to prepare TTAs.

Discharge information was shared with people's community pharmacy through the "Discharge Medication Service" (DMS). The DMS is an NHS collaborative communication scheme which aims to aim to improve medicine related outcomes and reduce readmission for patients on discharge from hospital. The service worked closely with local pharmacies in the provision of this service.

Staff we spoke with told us they knew how to access relevant local medicines policies, procedures, and guidelines including medicines information to supply to patients on discharge. Pharmacy staff provided regular training for staff of all positions, including training on specific medicines and the electronic prescribing and administration system.

The service completed regular medicine audits including clinical audits and safe and secure management of medicine audit. Wards completed a regular antibiotic snapshot audit to ensure antibiotic prescribing followed national and local guidance. Results of audits were discussed and shared with ward leaders.

The service had a medicines safety improvement plan for 2025 that covered areas of improvements identified by audits and learning. Each action had an owner and expected date of implementation. Whilst there were some actions that were 3 months overdue at the time of inspection, the majority were on target or completed.

Medicine related audits completed by the service identified similar concerns raised on inspection and we saw action taken to drive improvements as a result. For example, the service had recently introduced new antibiotic guidelines and identified some areas where the changes had not yet been embedded. The latest safe and secure handling of medicines audit results showed 97% compliance across all ward areas.