Croydon University Hospital

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• 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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question as good. At this assessment, the rating has remained good. This meant the service was managed and well-led. However, the leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the regulations for legal requirements under leadership and governance.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We scored the service as 2. The evidence showed some shortfalls. Not all service leaders were inclusive at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not always operate effective systems and processes, nor maintain clear oversight of maternity services to keep women, and babies safe.

The service had a defined leadership structure which included a clinical director, an interim director of midwifery, divisional manager and deputy director of nursing. They were supported by an associate director of midwifery, head of governance, consultant midwife, head of transformation and quality improvement, 3 matrons and 3 clinical managers. The service was also supported by board level maternity and perinatal safety champions, comprising of the chief nurse and a designated non-executive safety champion. The senior leaders reported good support and access to the trust board and maternity safety champions.

However, there were several interim leadership posts, including the director of midwifery, band 8b head of maternity and neonatal transformation and quality improvement lead, matron for maternity public health, and two band 8a clinical midwifery managers. Staff told and we observed this impacted on patient safety and the leadership and governance oversight to maintain performance and long-term sustainability of the service. During the assessment, we identified several issues with equipment, staff appraisal and training, records, and risk assessment completion, which raised concerns about leaders' oversight. Some staff felt they were not sure if the new leaders would make changes or restructure the service, and this made them nervous and anxious.

Leaders had the skills, knowledge and experience to perform their roles. However, staff did not always feel leaders were compassionate and inclusive. Staff reported that leaders were not always visible or approachable for women and staff in the service. Some staff did not know who the maternity senior leaders and maternity safety champions were. Some staff told us the senior maternity leadership team did not visit their maternity service, and they only saw them in their units during our assessment. We observed that the senior leadership team were based in the trust leadership building, which was away from the maternity service.

Leaders were not always aware of the service's culture and how it could affect the quality of people’s care. We received mixed feedback from staff on the service's culture, particularly between the senior leaders and front-line staff, and how quickly leaders address concerns. Some small number of staff felt some leaders showed favouritism and did not feel able to raise concerns. Whilst other staff felt their complaints and concerns raised with leaders were not always dealt with. A small number of staff told us that some leaders did not communicate respectfully, did not listen to concerns or care about women who accessed the service. Staff told us that some leaders needed more experience in communication, self-awareness, equitable staff care and being more non-biased.

Leaders did not always understand and manage the priorities and issues the service faced. They lacked clear oversight of significant gaps in service users’ records, triage, risk assessments and audits to ensure patient safety, service improvement and improved compliance. This resulted in several reported incidents and increased the risk of potential harm to women and babies.

Leadership development opportunities were available, including opportunities for staff. For example, the service had a senior health care assistant leadership apprenticeship programme for band 3 staff. It was unclear how many staff had taken this opportunity. The service had regular weekly senior leadership breakfast meetings, and staff told us this had helped improve their oversight of performance and collaborative working.

Staff and leaders had considered and understood national maternity specific recommendations such as the Ockenden report. However, there were 3 outstanding Ockenden actions related to the development of a national labour ward coordinator study days, HDU training for midwives, and funding for a preconception clinic for complex antenatal needs. The service reported no funding for pre-conception care and the timescale to have completed the action was January 2024. Whilst the trust was still awaiting the national study days for the labour ward coordinator, their integrated care board was reviewing funding and training opportunities to support the delivery of the actions. Some of the midwives were enrolled on HDU courses, and a further 6 places had been requested between July and September 2025. The benchmark tracker showed that both actions' baseline end date was January 2024 and did not include how often the actions were reviewed or last updated. This raised concerns around the service leader's oversight on this national recommendation. However, we saw evidence that the actions, challenges and progress were reported to the trust board quarterly and monitored by the local maternity and neonatal system.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

We scored the service as 2. The evidence showed some shortfalls. The trust did not always have systems of good governance to ensure risk and performance were identified, escalated appropriately, and addressed with timely action.

Leaders did not always operate effective governance processes throughout the service. There was a lack of effective processes, oversight, and governance to assess, monitor, and manage risks, incidents, triage, equipment and the environment, baby abduction risk, records, risk assessment, mandatory training, and appraisal to keep staff, women, and babies safe.

The risk register lacked adequate controls for all identified risks. For example, the risk register did not reflect issues found on our assessment and did not have adequate controls for all risks identified, such as tail gating, gaps in documentation and risk assessments, equipment, interim leadership positions, staff training and appraisal. The service had not taken timely action to address risks on the risk register, such as increasing the registrar workforce and considering the use of advanced care practitioners as an alternative to the obstetric workforce in triage. Also, the delay in obstetric assessment of women attending triage had been on the risk register since 26 August 2022 and was also identified in a recent external incident investigation of a stillbirth. This raised concerns that staff had not implemented recommendations from reviews of deaths, incidents and complaints.

The trust did not always ensure that incidents were reported and harm levels were assessed correctly, which hindered effective management of the service, reflected harm sustained by service users, and improved safety.

The governance team included an obstetric lead for governance, a band 8b head of governance, 4 band 7 specialist midwives, an interim audit and quality lead, a band 6 data manager and a band 3 maternity quality and safety administrator. The service had a vacancy for a band 7 perinatal mortality review tool (PMRT) midwife, and leaders advised this was a band 6 post which had been converted to a band 7 role. The audit and quality lead was covering the substantive postholder who was seconded to the lead practice development nurse role as they were on maternity leave. Staff told us the gaps and interim positions in the governance structure hindered the team's ability to deliver a safe and effective service and sustained improvement.

Managers and staff carried out a comprehensive programme of repeated audits to check improvement over time. The service participated in relevant local and national clinical audits. However, leaders did not always act on the results in a timely manner when needed to drive improvement to the service.

Staff at all levels were clear about their roles and accountabilities, and had regular opportunities to meet, discuss, and learn from the service's performance. The service held various governance meetings, which fed into the quarterly board assurance report. This included the perinatal incident review group, the intrapartum care group, clinical governance meetings, the transformation steering group, and the perinatal quality and safety group. The service had a 3-year maternity and neonatal improvement plan. The plan included listening to and working with women and families with compassion, staffing, a culture of safety, learning and support, and standards and structures that underpinned safer, more personalised and more equitable care.

There was a clear framework of what must be discussed at ward, team or directorate level team meetings to ensure that essential information, such as learning from incidents and complaints, were shared and discussed. However, senior midwifery staff told us the service did not have band 6 team meetings, and they felt this would help their learning, development and oversight of performance. Staff followed up-to-date policies to plan and deliver care according to evidence-based practice and national guidance.

The trust board minutes reviewed showed that maternity items were included in the monthly meeting papers and covered topics such as incidents, staffing, performance reports, Clinical Negligence Scheme for Trust safety action compliance (CNST), and the NHS staff survey. The trust board had declared they were compliant with all 10 of the safety actions of CNST: maternity incentive scheme (MIS) year 6 and were confident they would be compliant with Year 7. The service complied with 5 of the safety actions in CNST MIS Year 7, and we observed they were on track to comply with the remaining 5. The MIS is a financial incentive programme designed to enhance maternity safety within NHS trusts. It rewards trusts that can demonstrate they have implemented a set of core safety actions.

The maternity service had not fully implemented the Saving Babies’ Lives Care Bundle Version 3.2, which was introduced in April 2025 and is part of the national initiative to reduce stillbirths and neonatal deaths. The service reported 77% compliance across all 6 elements, with the diabetes elements fully implemented and the remaining 5 partially implemented with action plans in place. However, the service data did not include the timescale for the completion of actions. Post assessment, the trust advised and provided evidence to show that the action plan was monitored through the Saving Babies Lives Care Bundle tracker and quarterly report.

Data provided by the service confirmed that the perinatal mortality review tool (PMRT) meetings were held to review care and report on perinatal deaths that had occurred within the service. The service was compliant with reviewing and reporting of PMRT cases as per the Clinical Negligence Scheme for Trust: maternity incentive scheme (MIS) year 6 (CNST MIS) requirement.

The service collated and submitted data to Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) as required. The trust board papers showed that the service's stillbirth rate and neonatal death rate were lower than the MBRRACE 2024 and 2025 national averages.

The service collected reliable data and analysed it. They had a new maternity dashboard of performance, which was accessible to senior managers. Data or notifications were consistently submitted to external organisations as required such as Maternity and Newborn Safety Investigations (MNSI). The information systems were integrated and secure. Information governance systems included the confidentiality of patient records. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

The service had plans for emergencies, for example, adverse weather or a flu outbreak.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.