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

This was a focused follow‑up assessment for this service. At our last inspection, we rated this key question as requires improvement. During this assessment, the rating stayed the same. At this assessment we found there remained concerns with the way the service was led and managed and the rating remains requires improvement.

We assessed elements of 2 quality statement for the well led domain – capable, compassionate and inclusive leaders and governance, management and sustainability. Leaders were aware of concerns in the department and whilst they had taken some action, it was not enough to address the safety and privacy of patients in the 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.

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.

Leaders did not always take appropriate steps to manage risk and performance, despite having good oversight of the service. They identified corridor care as the most significant risk, which remained the highest risk on the department’s risk register despite mitigation plans. They acknowledged that care in these areas did not consistently maintain patients’ privacy and dignity and that incidents had occurred, or could have occurred, due to the busy and unsuitable environment. Leaders recognised these risks; however, they worked to prioritise patient safety, demonstrated awareness of the challenges, and had developed strategies to address them.

Leaders did not fully mitigate the impact of crowding and flow challenges, which meant patients were not always kept safe and their privacy and dignity were not consistently maintained. They acknowledged that the demands of the department and the use of non-clinical spaces for patient care increased the risk to both patients and staff. Senior leaders understood the pressures this placed on staff and the increased levels of stress. However, they remained visible, knowledgeable, and engaged, demonstrating a clear understanding of departmental priorities and challenges while working to improve conditions.

Leaders had not always ensured that risks relating to staff wellbeing and environmental pressures were fully addressed. However, staff consistently described leaders as supportive, approachable, and available when needed. Leaders fostered a positive culture, led by example, and demonstrated compassion towards staff, recognising the impact of service pressures and offering appropriate support.

Although there were challenges within the service, leaders maintained a clear structure and defined roles, including the clinical lead, head of nursing, and service manager, who worked collaboratively. They showed a shared understanding of risks and pressures within the department. Leaders ensured that staff understood their roles, responsibilities, and accountabilities, and they did not restrict opportunities for learning and development.

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.

Governance and management systems did not consistently ensure the delivery of safe, high-quality care or lead to sustained improvements in performance and patient experience. Leaders had established processes for escalation during periods of high demand, supported by standard operating procedures for escalation areas; however, incidents continued to occur in these areas. Staff and leaders recognised that corridor care compromised patients’ privacy and dignity, and patient feedback had repeatedly highlighted these concerns. Despite this, governance processes did not drive effective or sustained action to address these risks.

Governance arrangements did not ensure that long-standing flow issues were resolved. Patients continued to experience significant delays in admission from the Emergency Department, which contributed to overcrowding and meant that patients did not always receive timely or appropriate ongoing care. These pressures increased the use of escalation spaces that were not designed for clinical care and heightened the risk of harm. Leaders had identified these risks, including corridor care, overcrowding, and prolonged waits, but they remained on the risk register without sufficient reduction, indicating that governance systems were not consistently effective in mitigating or managing risk.

Leadership oversight did not consistently translate into improved outcomes. Leaders recognised that overcrowding, high activity, and long lengths of stay increased the likelihood of incidents and negatively impacted patient safety, experience, and staff wellbeing. They acknowledged that care environments, including ambulance handover areas and corridor spaces, were not fit for purpose and contributed to these risks.

Despite these concerns, leaders had implemented a comprehensive and structured governance framework to support oversight and accountability. They held monthly Emergency Department business meetings, including a paediatric forum, where senior leaders reviewed performance, strategy, and service delivery. This was supported by a monthly clinical governance meeting , which facilitated learning from incidents and review of quality and safety issues.

Leaders maintained oversight of risk and safety through a range of formal governance forums. They chaired monthly risk management meetings and a dedicated risk management group, alongside weekly incident review and oversight meetings. These were triangulated with weekly directorate incident review groups and twice-weekly complaints meetings, ensuring that incidents, risks, and patient feedback were reviewed and acted upon.

Leaders monitored performance through a bi‑weekly quality and safety group and monthly reviews of 4-hour and 12-hour standards. They escalated concerns through monthly directorate management boards and performance review boards, which provided assurance and accountability to the wider organisation.

Operational governance supported day-to-day management of demand and capacity. Teams held daily touchpoint meetings and site reviews, alongside weekly senior management meetings, to maintain real-time oversight of patient flow. Leaders strengthened system working through regular integration meetings with key partners, including ambulance services, mental health services, radiology, and community teams. They also used specialist forums, such as high-intensity user groups and violence prevention meetings, to address specific risks and population needs.

Multidisciplinary working formed a key component of governance. Staff completed daily nursing and medical handovers, regular multi-disciplinary team (MDT) reviews, and safety briefings, which ensured continuous clinical oversight and coordinated care delivery. However, although leaders demonstrated clear awareness of risks, maintained a comprehensive governance meeting structure, and ensured regular review and escalation of issues, these processes had not consistently resulted in sufficient or sustained improvements in safety, flow, or patient experience.

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.