Croydon University Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At our last assessment we rated this key question as Requires Improvement. The service was in breach of legal regulation in relation to good governance. At this assessment we found that there remained concerns with the way the service was led and managed and remains requires improvement

We assessed six quality statements. We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

There had been mixed culture in the emergency department. Leaders were aware of this and were taking steps to address it. Whilst leaders could describe the vision and strategy for the service, not all staff could and we were not provided with a strategy.

Leaders were aware of concerns in the department and whilst they had taken some action, it was insufficient to address the safety and privacy of patients in the department.

Governance systems were in place but not always effective. Data provided by the trust showed 368 incidents, some of which were from more than a year previous had not been closed. This meant we could not be assured all opportunities for learning had been taken. 30 incidents had been reported into breach of the cohort areas criteria which meant it was likely patients who should not have been cared for in that environment were. The service was aware of privacy and dignity concerns as well as long delays for admitted patients to leave the department but insufficient action had been taken to address this. The risk register had some risks that were originally included in 2023 and whilst there were mitigations in place the risk had not been closed since that time. Internal professional standards were just to be launched following our assessment.

Most staff were aware of the freedom to speak up service and were confident in raising concerns. The service worked in partnership with stakeholders and communities and there were examples of quality improvement initiatives in the emergency department.

We have not awarded this service a score for Well-led.

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

Not all staff were aware of the vision and strategy for the service.

There had been a mixed culture in the paediatric emergency department, with some staff describing a difficult culture before changes were made. There had been work undertaken to improve this including increased senior oversight and presence, professional role modelling and increased staffing and support as well as engagement. This had improved the culture though senior staff were aware there was still more to do to embed the change.

The strategic objective for the service `Achieving Excellence Together' had been developed following staff engagement in 2024. There was a focus on service development and highlighting areas for improvement. The themes were aligned to CQC regulations and there were timescales for the improvements to be planned and implemented. However, we were not provided with a formal strategy document which provided the department with a clear view of the future and where the service aimed to be with defined workstreams.

Senior leaders were able to describe the priorities for the department, that it was interlinked with other departments strategy and focussed on patient care and experience. They recognised that patient flow remained a significant issue but that they were listened to by the executive team. The trust response to the demands on the emergency department included the boarding policy, frailty unit and the SDEC. There was recognition of the effective pathways through UTC and GP hub and that further work was required to improve flow through the department and hospital.

We spoke with staff of varying seniority who gave inconsistent answers when we spoke about a vison and strategy for the service. Staff were extremely busy focussing on the immediate needs of patients and the department. They told us it was difficult to find the capacity to manage other things.

The trust recognised the need to increase management capacity and support in the emergency department. Additional staff had been recruited to add to this capacity and a number of staff had received management training to give them additional skills in leadership and management.

Workforce Race Equality Standard (WRES) was collated by the trust. Whilst the data relates to the trust rather than the emergency department it showed the trust performing broadly inline with comparator organisations. Senior staff spoke of promoting a culture of equality, diversity and human rights. Data was used to modify practices and develop the culture in response to the lived experience of staff.

Staff mostly felt supported and guided by their leadership team. The leaders were available when they were needed and led by example. They were knowledgeable about the issues and priorities in the department. The service had been without a director of unplanned care over the winter, but a new director had recently commenced in post.Leaders had good oversight of the service but had not always taken appropriate steps to manage risk and performance.

The leadership in the department included the clinical lead, the head of nursing and service manager. They described a positive working relationship and were well sighted on the demands and challenges of the department. They recognised the risks in the department and shared strategies and plans to address these. However, the biggest risk they identified was corridor care in the nurse cohort. Despite mitigations, this remained the highest risk on the departments risk register. Leaders had prioritised patient safety in these areas, but they acknowledged that privacy and dignity was not well managed. There had also been incidents in these areas that were or could be related to the busyness of the environment and that the intended use was not for patient care. Whilst leaders recognised the risk, insufficient steps had been taken to protect the privacy and dignity of patients being cared for in these areas. They were working to keep people safe but stated that flow was difficult and there was no single answer.

Senior leaders were aware of the impact that the crowded department has had on staff and that this increased stress. There were support services in place and actions to support culture had been implemented, particularly in the paediatric emergency department. However, staff told us previous winters had been very difficult to manage.

There was a recognition that leadership needed further capacity and development in the emergency department. This was partly related to culture. Whistle blowing information had raised concerns about leadership within the department. Staff had received additional training in management and leadership to increase capacity in the department. Additional leadership capacity was also required due to the busy nature of the department. Strategic planning and work was difficult due to the constant daily demands of operational management in the emergency department. The service recognised that leadership win the department had been supported and improved but required longer to embed and make changes in the department.

There had been a review of recruitment practices and there was inclusive recruitment and succession planning for the future. The trust had effective recruitment processes and ongoing checks to ensure all staff met the legal requirements to work in the trust.

All the staff we spoke with on assessment spoke positively of leaders. They felt supported in their roles and felt there was a positive attitude in the department. Leaders recognised the demands of the department on staff wellbeing and supported staff though we were told some staff took work home with them to complete as there was insufficient time at work.

There were positive examples of how leaders worked with external stakeholders such as commissioners and NHS England alongside other providers such as the ambulance service.

Leaders had effective support and opportunities to develop and maintain their skills. The roles of staff and leaders were clear, and they understood their responsibilities and accountabilities though further work was required to develop and maintain internal professional standards. All staff had opportunities to develop including for future leadership roles.

People did not always feel they could speak up and that their voice would be heard.

Whilst most staff were aware about Freedom to Speak Up and how to contact them, there were examples of staff not feeling able to raise concerns with the service, four members of staff contacted CQC about concerns they had in the emergency department.

The trust had commissioned an external company to provide the Freedom to Speak Up service which worked closely with senior leaders. The service identified key themes of concern which were reported to the division and the trust board. There were links with executives but also HR and staff wellbeing services. There had been an increase in contacts to the guardians since the commencement of the new service in late 2023.

Whilst the majority of staff we spoke to told us they were confident in raising concerns to managers, prior to the assessment we had received whistle blowing information that included concerns about raising issues within the department and culture among other concerns.

The board received information from the guardian service in respect of number of contacts made, the seriousness and theme of each concern realised with them. It was clear the service was able to access senior staff who would be in a position to effect change. Actions taken were recorded as well as outcomes. Staff could remain anonymous if they wished. The guardian service visited the emergency department monthly.

We spoke with two patients who both said they knew how to make a complaint should they need to.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Governance structures did not always support the delivery of high-quality care. Information and data were not always used to support patient safety and effective decision making.

There were clear processes for escalation at busy times which related to the emergency department and also other areas of the hospital. For example, when there were 45 patients in the emergency department, this initiated boarding protocols. The escalation areas had standard operating procedures (SOP) in place for their use. However, a review of incident data showed over 30 occasions in the last year that the criteria for the sub wait area was breached though there was no detail as to what the breach was. This meant that the cohort areas were not always used according to the SOP.

A further review of incidents showed that a number occurred in the escalation/ cohort areas which included a drug error and the misplacing of a medical device. One of the incidents made reference to the area being very busy with patients which contributed to the incident. There were 368 incidents that were overdue for closure. There remained a risk that potential learning was being missed due to the delay in closing these incidents. This meant we could not be assured that all available data was being acted on to reduce risk and safeguard patient safety.

The service was not collecting reliable date with regards medicines management. Data provided regarding medicines doses omitted for inappropriate reasons and critical doses omitted showed results well above the trust target. We were told that it was likely the results were lower than currently being reported but the method of data collection did not support that. This meant that we could not be sure data with regard medicine in the service was accurate for the service to monitor improvement in medicines management to keep people safe from avoidable harm. Plans were in place to address the issues with data collection.

The majority of staff we spoke with including senior leaders acknowledged the negative impact that cohort care had on the privacy and dignity of people being cared for in those areas. However, effective action had not been taken to address this. The service was aware of patient concerns regarding privacy and dignity from previous surveys.

At our last assessment we raised concerns about the time patients were waiting in the department before they were admitted. Data showed that patients still waited for too long for a bed which regularly resulted in crowding in the department and patients not receiving ongoing care in a timely way or which met their immediate need. This meant governance systems were not effective in identifying and managing risk or service improvement.

The Care Quality Commission UEC Survey 2024 showed the trust performing worse than expected for 9 metrics including Q.10 Were you given enough privacy when discussing your condition with the receptionist?; Q.31 While you were in A&E, did you feel safe around other service users and visitors?; Q.42 Overall, did you feel you were treated with dignity and respect while you were in A&E? On assessment we observed service users describing symptoms and personal information in reception in very close proximity.

Internal professional standards were due to commence the week following our assessment following a relaunch. However, medical staff we spoke with were unaware of what these were or whether they were in use.

Senior leaders in the department spoke daily with a weekly meeting for planning and strategy and focused on likely demands in the coming weeks alongside longer-term visions. There were 2 management meetings each month, one focussed on performance and one on delivery which were held at varying times so that different people could attend.

These meetings feed into the directorate management board governance meeting. The outcomes of the meetings were cascaded to staff in the department. We reviewed minutes of the business meeting in March 2025. The minutes were not clear in who attended the meeting and some of the notes had limited detail. We could not be assured that any actions identified at the meeting were being monitored to ensure they were being implemented. We also found that other meetings, for example police liaison meetings were not minuted. The primary purpose of meeting minutes is to provide an official, concise record of a meeting, including key discussions, decisions, and action items

The department risk register was monitored and updated and included risks for adult and paediatric emergency departments. There were 6 risks from May 2023. All had mitigations in place but not all had target dates for resolution. Some risks, such as ligature points in one area, had insufficient progress given the incidents that had previously happened in the department and identification of some areas such as bathrooms being high risk. This meant we could not be assured all reasonable actions were being taken to address risks.

Policies and procedures supported staff to manage major incidents. Staff were able to describe major incidents and what to do in the event of one.

The trust worked with commissioners and stakeholders and the local system and there were positive relationships. We saw evidence of regular meetings with other stakeholders to discuss pathways and any areas of concern. There was a desire to develop a shared understanding of the challenges in the system and identifying ways to improve.

There had been ongoing quality reviews of the department, where information was shared to encourage collaboration across departments and providers to improve quality, effectiveness and safety for people using the service.

There was evidence of engagement with staff and stakeholders and patients to develop pathways and improved care for people with certain conditions, including sickle cell disease.

There was evidence of sharing information with stakeholders to improve patient outcomes. This included pathway planning, redesign and implementation.

Staff were supported in learning and innovation.

A new triage system had commenced shortly before our assessment. It had reduced triage times as well as ensuring patients had early clinical review and oversight. Staff had been involved in the development and an evaluation was planned. There was recognition that some areas needed improvement and staff were committed to ensure these were addressed.

The department was involved in education and research which included thematic reviews of patient cases to present to the wider team to help improve patient outcomes as well as timely access to pain relief for patients with sickle cell disease.

Mortality review group meetings were held monthly. Minutes showed appropriate discussion of identified cases and identified learning to feedback to teams.

Staff we spoke with were able to tell us about quality improvement projects in the department such as behaviour disturbances and time critical medication.

Quality improvement projects were supported by the quality improvement lead in the trust. Projects were linked across departments and formed a strategic approach with increased executive support.