Croydon University Hospital

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• 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

We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. The service was in breach of legal regulation Safe care and treatment and Staffing.

The service had made some improvements though we identified concerns with the environment, management of incidents and medicines. Patients’ pathway of care sometimes meant they were cared for in areas that were not designed for patient care including patients requiring support with their mental health. Doctors mandatory training was low and children’s safeguarding training was also below trust target. Staff gave us inconsistent information about how the Mental Capacity Act was followed in the department.

Patients documentation was inconsistently completed with some risk assessments not being completed or acted upon.

The new triage system had a positive impact on the time it took for people to be reviewed and see an appropriate clinician. The waiting area had low acuity and clinical oversight.

National Early Warning Scores (NEWS 2) were completed regularly and results acted upon. There were the right numbers of competent staff available and we saw staff following infection, prevention and control procedures when carrying out their work.

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.

Staff reported incidents, but they did not always receive feedback. Whilst lessons were learnt we saw examples of delays in the closure of incidents. Staff told us they had no concerns in reporting incidents.

The trust used NHS England’s Patient Safety Incident Response Framework (PSIRF). This meant the trust focused on effective learning and compassionate, meaningful engagement with those affected when incidents occurred.

Staff told us they knew how to report incidents and were supported to do this. The trust had moved onto a new system for reporting incidents. Senior staff were supported by the patient safety team where required. Not all staff were aware of learning from previous incidents. The department circulated ‘Incident at a glance’ which succinctly identified learning from an incident for staff awareness. However, not all members of staff we spoke with were aware of learning about recent incidents that had happened in the department.

Information provided by the service showed that eight Patient Safety Incident Investigations (PSII) had been completed between September 2024 and March 2025. We reviewed one PSII which had identified appropriate learning and had strived to involve the patient’s family in the investigation. There were 368 incidents assigned to the emergency department that had yet to be closed with the oldest being from November 2023. All were low or no harm. We were informed that all had been reviewed but the delay in closing incidents meant incidents were not fully managed in a timely way.

Data provided by the trust showed that between September 2024 and March 2025 1018 incidents had been recorded in the emergency department and urgent treatment centre. The top three themes were bed management, pressure ulcers and medication. Information we reviewed showed that Duty of Candour had been appropriately carried out in relation to the incidents we reviewed. All the staff we spoke with where aware of their responsibilities under the professional and legal duty of candour.

Clinical governance meetings were held by the department which was attended by staff of differing roles and grades. The agenda included a review of incidents in the department and identified learning. The record we reviewed was a paediatric focus which reviewed several incidents and identified learning as well as when things had gone well.

There was a process in place to manage safety alerts. The Central Alert System Policy outlined procedures for patient safety alerts and MHRA alerts amongst others. Senior staff we spoke with were clear how this was managed and their responsibilities under it.

There had been 56 complaints between June 2024 and February 2025. The three main themes were patient care and treatment, admissions, discharge and transfers and values and behaviours of staff. Senior staff were involved in reviewing complaints and incidents and were aware of these themes and learnings which were incorporated into governance meetings. We reviewed responses to complaints. They had been properly investigated, apologies given and learning identified. Duty of candour was monitored through the Clinical Safety Group.

The department worked collaboratively with internal colleagues and external partners to maintain patients' safety. However, there were delays in ensuring patients were cared for in the correct area once a decision to admit had been made. The use of areas that were not designed for patient care increased the risk to safety. Not all specialties responded promptly to being contacted

Due to delays in admitting patients to an inpatient bed, patients were cared for in the wrong area. For example, on the first day of our assessment at 4pm, all 28 majors cubicles were taken by patients who had been admitted by a speciality but where there was not yet a bed available. This meant they were not being cared for in the correct area to meet their needs.

Due to a busy and crowded department, patients were cared for in escalation areas that were not designed for that purpose. They lacked some facilities such as call bells and emergency alarms. The use of nurse cohort corridor which joined the resuscitation room, majors subwait area and the ambulance arrival area meant that it could be difficult to move patients and equipment through the area. We observed one patient moved from resuscitation for imaging and trolleys with other patients on had to be moved around to allow the patients from resuscitation access to the corridor and towards the imaging department. They had to be moved very closely to other patients waiting in the corridor. This increased the risk of serious avoidable harm as the use of essential life saving equipment may be impeded due to lack of space.

Staff told us that when making referrals they could wait long periods for a response from the receiving specialty. On our assessment we observed emergency department staff attempting to contact 3 specialties and only one responded within thirty minutes.

The department had recently introduced a new triage and streaming model which ensured people received care in the most appropriate place. The new model had reduced triage times and ensured early clinical oversight of patients. The streaming to the urgent treatment centre (UTC) was an effective pathway and delivered care to over 170 people a day. Other streams were to the same day emergency care unit (SDEC) and the GP hub which saw redirection totals of around 1100 per month.

Triage in paediatric emergency department (ED )was conducted by staff with additional training that met national guidance. There was a holistic assessment of physical, emotional and mental health needs. Staff reported positive relationships with the Child and Adolescent Mental health Servies (CAMHS) as well as child safeguarding teams.

The Trust was piloting enhanced streaming for the paediatric emergency department. The total percentage of nursing staff members trained in the Manchester Triage System or currently completing training was of 73%. We were told that the trust had allocated a full time practice development nurse for one year, to run the triage programme.

Patients who did not wait to be seen were contacted by the department to ascertain if they still needed care. This was recorded in the electronic patient record.

The electronic patient record contained care plans and pathways in line with best practices and other trust policies and procedures.

Records and risk assessments were inconsistently completed. We reviewed 11 adult records and in 5 of them no falls risk assessment had been completed and no skin assessments completed. The longest period a patient had been in the department was 18 hours without these completed. Staff told us that these should be completed within 6 hours. Incident data showed a number of incidents in relation to falls in the department. This meant there was a potential delay in recognising, managing and preventing falls and skin damage. ECGs results were paper based and not part of the electronic patient record. This increased the risk of results not being available or reviewed.

We reviewed 4 paediatric records. One record had no documentation by nursing staff or the specialty that reviewed them. We escalated this at the time of the assessment and action was taken to address this.

Mental health assessments were carried out at triage and on admission. The emergency department cared for a comparatively high proportion of patients requiring care and support for their mental health. Mental health risk assessments were completed and there were dedicated mental health nurses to support them. Data provided by the trust showed that staff had completed specialist mental health training for those completing triage. An associate director of nursing for people with mental health needs supported the department.

There was access to psychiatric liaison at all times for adults and children and staff reported a positive working relationship. There were pathways in place with other services for review and care of these patients though we were told there could be delays in patients being cared for in a suitable placement. This meant that, at times, the department was caring for more patients with a mental health condition than they had appropriate facilities for. Data showed that the average time in the department for people with a mental health diagnosis was over 16 hours. At the time of our assessment the longest wait in the emergency department for a patient with mental health needs was 62 hours.

There was one CAMHS bed available for children who needed this support. Staff told us that it was insufficient and that they cared for more children with these needs than the one room allowed. They described an incident when a child patient was cared for in the CAMHS room for an extended period of days waiting for a specialist bed. Whilst staff provided appropriate care they recognised the need for the patient to be cared for in the correct place.

Handovers were held each day at 8am and we saw that detailed information was handed over including peoples current and likely care needs as well as the plan of care for each patient. Board rounds were conducted three times a day in addition to this. A board round is a structured daily meeting of a multidisciplinary team (MDT) focused on reviewing patient care and progress.

We observed a board round and handover which was attended by the multidisciplinary team in line with Royal College of Emergency Medicine (RCEM)guidance for handovers.

Ambulance handover delays were minimal.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. However, safeguarding training did not meet target and staff gave inconsistent information about mental capacity assessments.

Staff we spoke with knew how to recognise adults and children at risk of abuse or harm. The department worked with other agencies including the local authority and police to protect people from abuse. The trust leads for safeguarding supported staff with safeguarding concerns where it was needed. There was no safeguarding lead in the paediatric ED though senior staff told us there was plans in place to recruit to this position.

Staff undertook training in safeguarding and how to recognise abuse and how to manage it. Data provided by the trust showed that 89% of staff has completed safeguarding adults training relevant to their role though this fell to 70% for child safeguarding training. The trust target was 90%. Mental Capacity Act training was included in the safeguarding adults training.

Safeguarding polices were in place which was supported by relevant legislation. Paediatric safeguarding was a priority in the paediatric ED with good links to the local authority safeguarding team and a clear process to flag and refer any concerns to the relevant professionals.

Staff in both the paediatric and adult emergency department told us they were confident in reporting safeguarding should it be required and were supported by senior staff with specialist knowledge in the trust if it was needed or if there was a complex case that required managing. Records included a flag for patients who may have safeguarding needs which alerted staff to this.

There was a domestic abuse champion in the emergency department. Furthermore, the safeguarding team attended ED with a domestic abuse advocate twice a day to offer support to anyone who may require this. There were flags on acute and community records for domestic abuse so that staff in all settings were aware of risk

We received mixed information about staff completing Mental Capacity Act (MCA) assessments. Several staff told us that it was the doctors who completed these assessments though the ability to carry out an assessment may be needed by all staff working in the emergency department. There were a number of inconsistent responses about how they should be completed. Senior staff told us they knew that additional work and focus was required for staff understanding of MCA. Reviews of records showed that not all mental capacity assessments were completed fully. We were told that issues with MCA and DoLS are recurring themes in local authority safeguarding reviews.

The department had effective processes and tools for assessing patients when they first presented to the department and monitored patients for signs of deterioration when they remained in the department for extended periods of time.

There were effective processes in place to assess patients in the department. Time to triage had improved since the introduction of a new triage model. Time to triage was consistently better than 15 minutes. This also meant that acuity was low in the waiting area where there was also clinical oversight.

The trusts used the National Early Warning Score (NEWS 2) to assess patients at risk of deterioration in the department and enable staff to take appropriate action. In the paediatric department this was the Paediatric Early Warning Score (PEWS). Staff were clear how to escalate patients that needed clinical review. Records we reviewed showed that staff complete the observations and scores as required by the protocol and properly escalated for review where they needed to.

Audits were completed which showed good compliance with NEWS 2. For PEWS audit results had improved from 80% in July 2024 to 100% compliance in March 2025.

The trust was a pilot site for Martha’s Rule. Martha’s Rule is a major patient safety initiative providing patients and families with a way to seek an urgent review if their or their loved one’s condition deteriorates, and they are concerned this is not being responded to. The trust operated Call for Concern which was in line with Martha’s Rule. The Call for Concern allowed patients, relatives or friends who felt they were getting worse to be seen by a senior clinical member of staff urgently. A dedicated phone number was available that went directly to the critical care outreach team that managed the referral and reviewed the patient.

The Urgent and Emergency Care Survey 2024 showed worse than expected responses for communication including if patients were told how long they would have to wait, the ability for a family member to speak to a nurse or doctor and whether staff discussed the need for further care.

Security staff had received training in how to manage violence and aggression and de-escalation and least restrictive restraint. Data provided by the trust showed that 100% staff had completed this training.

The department was often crowded with patients cared for in inappropriate spaces such as corridors. Corridor care made it difficult to use necessary medical equipment. Whilst staff were aware and managed some risks of corridor care, the environment in the cohort areas were not appropriate for patient care.

The facilities were well maintained, and any equipment used with patients was in good working order and used safely to support the delivery of safe care. Staff wore personal protective equipment in line with regulation.

Hazardous and clinical waste was responsibly managed. The department’s fire safety and other emergency systems were tested and maintained.

There was cohorting care in the majors sub wait area and the nurse cohort corridor which linked the ambulance arrival area with the majors area of the department. Both areas were extremely busy. The corridor was brightly lit with one toilet and offered no privacy. The sub wait area had recliner chairs which were very close to each other, again limiting privacy. Data provided by the trust showed that patients were cared for in these areas for long periods. The environment also reduced the space for other patients being moved through the areas or being brought in by ambulance. Staff we spoke with of varying seniority told us that their main concern about the department was delivering corridor care.

There was clinical oversight of cohorting areas by registered staff and the new approach to triage meant the waiting area was clearly visible to clinical staff. There was comparatively low acuity in the waiting area and the cohort areas at the time of our assessment.

The rapid assessment and treatment area (RAT) was located adjacent to the sub wait area. When busy with people waiting this led to further crowding in the department.

The paediatric ED was a separate area for children and families. There was adequate space and there was no overcrowding in the department during our assessment.

There was a separate area in the department to care for people who required support and treatment for their mental health which enabled assessment in a private way. However, staff told us that the rooms were not always sufficient for the number of people requiring this care. An incident in March 2025 indicated that a patient was in mental health crisis and there were no mental health rooms available for their care.

Records of maintenance and portable appliance testing were held centrally. All the equipment we checked in the department including emergency equipment appeared clean and had been properly tested.

People told us they felt there were enough staff with the right skills and experience to look after people safely. They said the staff were well trained and competent with the care and treatment they were providing.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, not all consultant staff had completed mandatory training. They worked together well to provide safe care that met people's individual needs. Staffing was planned and managed according to national guidance with appropriate staffing in the paediatric emergency department. Staff had extended competencies to safely care for patients in specific areas of the department. There were opportunities for development and staff received appraisals.

The department had recruited significantly more staff since our last assessment, particularly in the paediatric department. Due to the recent recruitment, the nursing workforce were comparatively new, a risk recognised by the department. There were plans to support them, develop their skills and experience and dates booked for training.

There had been a significant effort in recruitment and upskilling the Paediatric ED team and promote retention. Service leads reviewed the recruitment process which had proved to be effective. The need to increase competencies and skills was included in the departmental risk register.

Senior clinical staff had been successfully recruited into both the adult and paediatric emergency department which had been a concern at our last assessment.

There was a skilled multidisciplinary team which supported the development of new roles and functions in the department.

Staffing was monitored daily in the department and at escalation meetings. As required, additional staff could be utilised when demand required additional resource. Senior staff told us that if they requested additional staff, they were supported in doing that. Whilst use of agency and locum staff was generally low, the mental health nurses were agency staff as the trust had found this a difficult role to recruit to.

Most staff were up to date with mandatory training. Data provided by the trust showed that 85% of nursing staff were compliant with mandatory training but this fell to 50% for consultants. Consultant staff had completed other training such as advanced life support which mitigated some of the risk of not being up to date with mandatory training. Other medical staff was 81%. The trust target was 90%.

Medical staff had completed advanced life support for adults and children. Data provided by the trust showed that 89% were up to date with this training. Due to the recent recruitment of new paediatric nursing staff, compliance was lower for advanced life support though we saw that other staff had been booked on training.

Staff were supported to undertake additional training and completed competencies such as triage to ensure they were supported, developed and safe in their roles.

Vacancy rates for consultants was 0% and resident doctors was 11%. There were low vacancy rates for registered staff though some vacancies for unregistered staff in the adult emergency department.

Rotas showed that there was appropriate staffing on each shift and low use of locum and agency staff. Data provided by the trust showed most shifts were filled.

Staff received appraisals though consultants and nursing staff were at 85% completed against a trust target of 95%. Resident doctors had all received an appraisal.

Sickness rates were 7.9% for health care support workers and 6% for nurses which was above the trust target of 3.5%. Doctors' sickness was 1.7%.

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 told us that they can received support from learning disability and autism champions when required. The trust had implemented training in relation to the care of people with a learning disability and autistic people. Tier 1 training had been attended by 90% of staff with rollout of Tier 2 training underway.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff followed infection prevention and control (IPC) guidance, washed hands between patient contact and wore appropriate PPE. Patients who required to be cared for in isolation were able to have single rooms and staff managed effective barrier nursing.

The department had a designated infection, prevention and control lead and had had relevant training. Cleaning schedules were in place and followed.

We observed staff following IPC guidance, were bare below the elbows and washed their hands before patient contact. Hand sanitiser was available throughout the department.

The department areas looked visibly clean. We saw cleaning staff regularly and checklists showed that cleaning schedules were maintained. Hygiene audits were completed that showed good compliance.

The department managed and monitored the type if infections that were identified in the department and there were clear processes for escalating notifiable diseases and the appropriate reporting. There was access to specialist personal protective equipment if required. Staff were pre alerted by the ambulance service if a known infectious patient was being brought to the department.

The emergency department was a very busy area and patients were sat in close proximity to each other in the escalation areas. The risk to the spread of infection was recognised by the department and in risk assessments, however, staff told us they remained concerned about this risk. There were no patients with a known infectious disease in the cohort areas at the time of our assessment.

The department undertook audits of infection prevention and control including hand hygiene. Data provided by the trust showed that hand hygiene was 95% compliant in December 2024. The IPC audit showed improvement to 98% between October and December 2024. Actions for improvement were identified.

We could not be assured that medicines were always given as prescribed. From records we reviewed on the day of assessment, we saw people generally received their medicines as prescribed in a timely way, including antibiotics that were prescribed for sepsis.

However, we saw one instance where a high risk medicine was delayed. This was because staff could not find the stock. Furthermore, data provided from the trust after the assessment showed that 15% of doses were not administered due to inappropriate reasons and 7% of critical doses were not administered in March 2025 against a trust target of 1%. Leaders told us that this was inflated due to incorrect recording of omitted doses. We saw this on assessment where medicines omitted for clinical reasons had been inappropriately recorded as unavailable. The results of these audits were discussed at medicine safety meetings and actions were being discussed to improve future compliance.

Staff prioritised medicine reconciliation for patients with time-critical medications identified on the electronic prescribing and medicines administration system and generally achieved medicine reconciliations within 24 hours of presentation for these patients. There was some clinical pharmacy service to provide clinical reviews, medicine reconciliation and provide advice to patients and carers about their medicines. However, the level of support was not in line with national guidance produced by the Royal College of Emergency Medicine. Furthermore, staff and leaders told us that this support was currently temporary. They told us that a further reduction in the level of support could increase medicine related risks for people in the ED. Leaders told us that the pharmacy support to the ED was currently under review.

Venous thromboembolism (VTE) risk assessment outcomes and prescribing were completed on all patients notes that we reviewed.

Medicines were stored in dedicated secure storage areas with access restricted to authorised staff. In some areas, the service had an automated medicines dispensing cupboard (AMDC) which supported staff in selecting the correct medicines and replenishing stock. Staff could also order stock themselves via an electronic order system when required.

However, there was poor organisation and storage of medicines in the clinic rooms. Medicine stored in AMDC were not always stored in their original packaging. We found loose strips of different medicines stored together increasing the risk of mis-selection during busy periods. This was not in line with the services policy and was raised with leaders to review.

Further, in the major's clinic room, we also saw IV fluids unpacked from their original packing into baskets. However, the baskets were not clearly labelled. This is not in line with national guidance. Fridges were not kept tidy. We saw staff struggled to find stock that was in the fridge. In the paediatric ED, different IV fluid bags were not always stored separately. Labelling helps healthcare professionals quickly identify the type of fluid, its contents and correct expiration date. This is vital for administering the right fluid, dose, and rate, minimising the risk of adverse events like fluid overload or electrolyte imbalances.

The service audited the safe and secure handling medicines storage every 3 months. However, the audits failed to identify areas for improvement found on assessment.

Emergency medicines and equipment were available. There were tamper evident seals in place to ensure they were safe. Staff recorded weekly safety checks on emergency medicines and equipment to ensure they were safe to use if needed in an emergency. All expiry dates we checked were in date. However, expiry dates of emergency kits were not always recorded on checklists or on the sealed kits themselves.

Controlled drugs (CD) were stored securely. However, staff did not dispose of unwanted stock in a timely manner. In the major's area, we found multiple patients' own controlled drugs stored in the controlled drugs cupboard which were no longer required. Some of these were for patients who had attended the ED over 2 months earlier. CDs that are no longer required should be removed promptly to reduce the risk of diversion. Discrepancies in records of CDs were not always escalated appropriately. For example, we saw that a discrepancy for a medicine was identified but the date that the discrepancy was identified was not recorded, and the discrepancy had not been recorded as rectified. This was raised to staff to review.

There was a process for supplying medicines to patients including to prelabelled medications, outpatient prescriptions, and FP10 prescriptions.

Staff told us they had easy access to medicine resources to support them in their role including national and local guidelines. One patient we spoke with did not feel reassured about the care they were receiving in terms of their diabetes management and that staff did not understand their insulin regime.