Our rating of services stayed the same. We rated it them as requires improvement because:

• In medical care, there were large number of outliers and patients being moved at night.
• The service was reliant on the use of bank and agency staff to cover gaps in the staffing provision; however the trust could not be assured agency and bank staff were being inducted onto wards appropriately or when they commenced on a new ward.
• The trusts own internal audit data for hand hygiene within the service identified compliance was variable across the medical wards. Compliance varied from between 100% and 56%.
• Maintenance on the medical care wards and equipment was not always undertaken in a timely way. We found that repairs to windows on one ward had been waiting for six months.
• Wards had little public health information on the national priorities to improve the population’s health on smoking cessation, obesity, drug and alcohol dependency, dementia and cancer.
• Medical outliers were treated on surgical wards. The trust reported that over the last 12 months for the period April 2017 to March 2018 the number was 9,646.

However:

• There was a clear leadership structure within the medical care core service.
• There was a culture of honesty, openness and transparency within the service. We saw evidence of senior staff carrying out duty of candour responsibilities which detailed the involvement and support of patients or relatives in serious incident reports.
• We saw evidence of secure record keeping within the medical care core service.
• Serious incidents were discussed as part of the monthly patient safety and mortality committee meetings and the integrated adult care governance. SIs were investigated, had an action plan and lesson learnt identified.
• The trust had introduced a ‘10 steps’ meal distribution process to ensure that patient received their correct diet. Protected meal time were being strictly observed. Nursing staff were on ward so they could support and monitor patients who required assistance. The nurse in charge checked to ensure that patients were being given the right food which was checked against menu sheets and the nutrition boards.
• The results of recent published audits showed the service to be performing in line with national averages. In some cases where performance fell below the England average there was an improvement seen since the previous audit.
• There was effective multidisciplinary working within medical care.

A summary of services at this hospital appears in the overall summary above.

We reviewed the services within the Emergency Department (ED) and the Acute Medical Unit (AMU) of Croydon University Hospital. Our findings relate only to those two areas. Urgent care services within the hospital are hosted by Assura Wandle LLP. As these two services co-exist within the same building they have a direct relationship on each other’s function. Therefore an inspection of the Urgent Care Centre (UCC) was undertaken at the same time.

During our inspection we saw several examples of good care and all of the people that we spoke with told us that they had been very happy with the treatment that they had received. People told us staff were “very kind and caring” and kept them informed about why they were waiting. They considered that they had been involved in decisions that were made about their care.

However, we did find evidence that people’s needs were not always being met in a way that was safe and effective. We judged that the skills and expertise of staff was not always sufficient to meet people’s needs and keep them safe. We also raised concerns about the potential safety of people who were treated in the ED having initially been assessed in the UCC. We also raised concerns about the state of disrepair of the department.

As a result of our inspection we have identified shortfalls in three of the essential standards which all hospitals are required to comply with.

We spoke to six patients and all of them told us the surgical procedure they were about to undergo had been explained to them and staff had made them feel at ease. They told us that all of the staff that they had come into contact with at the hospital had treated them with respect. One patient said “Staff have been reassuring and as good as you would hope them to be.” Another patient said “They are marvellous but work very hard. I’m amazed at the amount of paper work they have to do.”

We saw that patients had their privacy protected during all stages whilst in theatre. All grades of staff ensured patients were covered with blankets and drapes when being transferred from bed to theatre table and whilst being prepared for their operation.

We observed staff interacting with patients in a kind and courteous manner. The language and tone of voice used by staff when talking to patients was always appropriate and was clearly intended to put people at their ease.

This inspection was carried out under section 62 of the Health & Social Care Act 2008. We performed this inspection to check on action taken by the trust following warning notices imposed at our previous inspection in June 2012. At that time the trust had experienced four serious incidents, classified as “never events” within the theatre areas at the hospital. “Never events” are defined by the NHS National Patient Safety Agency (NPSA) as “Serious, largely preventable, patient safety incidents that should not occur if the available preventative measures have been implemented.”

During our visit, we went into six theatres (Main theatre 2, 10, 6 and the ophthalmology theatre). We also visited theatres 1 and 4 within the day surgery department. We did not visit the maternity theatres as there was no elective surgery planned that day.

We watched the various stages of fifteen theatre checklist techniques being performed. We saw three sign in checks, seven time outs checks and three sign outs. The checklist identifies three phases of an operation, each corresponding to a specific period in the normal flow of work as follows: Before the patient has the anaesthetic (“sign in”), before the operation starts (“time out”) and before the patient leaves the operating room (“sign out”).

Part of the inspection was also to check on availability of equipment within the hospital overall as we had concerns during our last visit about the lack of equipment in some parts of the hospital. We visited the maternity unit, three wards and the accident and emergency department to check on equipment levels.

A team of representatives, from the Care Quality Commission, visited Croydon University Hospital as part of a planned review of compliance. The team included compliance inspectors, a compliance manager, analysts and a professional clinical advisor.

Over the course of four days we visited ten wards, including the maternity unit, the Accident and Emergency Department (A&E) and the discharge lounge. A team of inspectors, with the professional clinical advisor spent a day in the hospitals operating theatre suite.

We spoke with patients and members of staff, both clinical and non clinical, asking them about their views of the service. We looked at a sample of records including care plans and staff training records. Our analyst team also looked at information relating to staff rotas, complaints and notifications.

On wards caring for older people we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who are not able to talk with us.

We also had meetings with the chief executive officer and senior managers in the trust and asked them for a range of further evidence relating to staffing levels, staff training, notifications, patient feedback and complaints.

All of the staff that we spoke with were welcoming, open, and receptive to the inspection process. We would like to thank them for their help.

Individual patient feedback on the wards that we visited was, in the main, positive.

Comments included “staff are wonderful”, “all the staff are very good here”, and “I could not speak more highly of staff, and they’re a really good bunch”.

However, we did receive some adverse comments from patients, regarding staff attitude, saying “staff are sometimes a bit cold or dismissive although never unkind”. We reported this to the ward managers and we were assured that it would be addressed.

The perception of many people was that there were not enough staff and they told us “staff are constantly busy”, there never seems to be enough of them” and “the nurses seem to be able to cope most days but you can see that they’re stretched”.

We observed one example of a shortage of staff impacting on the care of one patient and were told about others.

On the maternity unit women told us their care had been “very good”, “excellent and a good experience”. They said the midwives and doctors had “been calm and reassuring”, “stayed with me and made sure I understood what was happening”, and “helped me to stay calm when I was so worried”.

Throughout the hospital we observed patients being cared for in a kind and respectful way. All levels of staff within the hospital showed respect when they were addressing patients and we heard examples of them checking that patients were comfortable and understood what was happening.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We made an unannounced visit to Croydon University Hospital on 22 November 2011 and spoke to people in Accident and Emergency (A&E), Queens 2, Wandle 3, Purley 3, Heathfield 2, and Rupert Bear wards.

A public interest disclosure letter had been received by the Care Quality Commission (CQC) prior to the visit taking place. As the regulator, CQC considered these concerns and other information received about the service since our last review.

The majority of people we spoke to said that they had been given good information about their care and confirmed that everything had been explained to them. We observed curtains consistently pulled around beds for privacy and staff interacted with people in a calm and respectful manner during our visit.

We spent time on two wards caring for older people and spoke to a number of people and their visitors who all reported they had been treated with dignity and respect. Comments included, "they are all nice – very polite", "they have been so kind" and "they are overworked but I find them all very very good".

Individuals generally felt that staff worked very hard however they made comments about staff being "overstretched", "hard pressed" and "overworked". One of the people using the service felt that there were not enough staff particularly when caring for people who have dementia. This view was shared by some of the staff and a visitor whose relative was living with dementia.

Feedback from other wards was that staff were hard working and were generally available when needed. They also told us that staff members were friendly and helpful. Individuals who had attended the hospital in previous years reported that there had been an improvement in staff attitudes.

On balance, the people we spoke to were generally positive about the care that they received at Croydon University Hospital although the majority also made comments about how busy or overstretched staff were.

All of the people we spoke to about cleanliness and hygiene reported that the wards were always kept very clean. Patients commonly described cleanliness within the hospital as "very good".

We would like to thank all of the staff and people who helped to facilitate this review and share their experiences.

We visited Croydon University Hospital maternity department on two separate occasions as part of this review. We acknowledge that on 14 July 2011 the unit was relatively quiet and on 5 October 2011 the unit was busy.

We would like to thank all of the staff and people who helped to facilitate this review

and share their experiences.

During our visits to Croydon University Hospital maternity unit on 14 July and 5 October 2011 we spoke to people on the postnatal ward. Overall the feedback from patients was positive with them all feeling that they had received good care and that the staff were kind, helpful and respectful of their dignity. They were positive regarding their births and reported that they were given information and involved in decisions during labour.

On 5 October we spoke to some patients on the antenatal ward who had already given birth, but were on this ward because the postnatal ward was full. All of these patients were positive about the information they had received on the labour ward, however some women said they had not had any information since being on the antenatal ward.

In terms of care on the postnatal ward, the women said that staff were around less during the night, although they attributed this to staff giving them time to sleep. They said that staff responded quickly if called for and would provide more support if asked.

All four patients we spoke to reported that they had received pain relief when they wanted and were happy with that part of the service. However one "Just a Minute" (JAM) - feedback cards available for people to complete - for the postnatal ward stated,

"Postnatal care on readmission has been good. However on occasion have had to ask 2-3 times for pain relief before being attended to."

The majority of JAM cards that had been completed the week prior to our visit on 14 July 2011 contained positive feedback about the quality of care. Comments included,

"Quality of the care given by all the staff. All my needs and baby’s needs were met."

"Mid-wife was very helpful and supportive. She made the delivery very easy. Very happy."

During our visit on 5 October we received more mixed views from people about their care. The majority of women on the postnatal ward reported having 1:1 care throughout their labour and were positive about the care they received during labour. All patients said that they received the pain relief they wanted and without delay. In terms of care on the postnatal ward, patients thought that staff were not around very much. They said they were helpful when they were available and the care patients had received was good. However, one patient said that she had been told by a midwife that she would be washed, but that it hadn’t happened. Another patient asked for pain relief, but it didn’t arrive and she had to call again.

However some of the women who had already given birth, but were on the antenatal ward because the postnatal ward was full, were not happy with the care they had received on this ward. They told us they had not been seen by staff and one of the patients was particularly concerned as her baby was supposed to be monitored four hourly and it hadn’t been happening, despite their requests.

We looked at complaints received and noted the number increased following the publication of our review in April 2011 and CQC were contacted directly by two people with concerns about care they, or a family member, had received. However the number of complaints has levelled off to below expected numbers in recent months. The majority of complaints related to aspects of clinical treatment.

We did not receive any negative comments from people we spoke to about the maternity unit environment. One person attending an appointment at the birthing unit particularly liked the way it was decorated to create a homely environment.

Overall patients we spoke to on our visit were positive about their care and treatment.

However the patients we spoke to commented that they did not feel involved in decisions about their care and did not know who to complain to. Most had not been provided with written information about the wards they were on.

We generally received positive feedback from patients about mealtimes, although two people did not like the food. Patients told us they were given choices of food and drink. We were also told that the food was always hot and fresh water was provided every day. Feedback included, “it’s quite a good choice”, “I don’t eat fish – they know that”, and “no complaints”.

During our visit to Croydon University Hospital maternity unit we spoke to patients and their relatives about their experiences of receiving care. One person told us that their experience had been, "Not as good this time", in comparison to having previous children at the hospital. Whereas another person told us, "They are looking after me well’ and "it’s good".

Other people talked to us about the poor experience they had throughout their time in the maternity unit. Some comments included

“When you press the buzzer, they take time to come. Not happy to help.” Asked more than 5 people and they didn’t come back. “Just want to check baby”.

“At night, they don’t walk around to check on you.”

“Nobody has changed the [drinking] water since yesterday.”

“Attitude of the staff is horrible.” “Only midwife has been nice.”

“Customer care zero. Patient care zero.”

“Hospital has changed name, but needs to change its service.”

People on the post natal ward gave us the following feedback about the environment, "I like having a single room".

"it’s been lovely – very quiet".

People we spoke to said, "The staff are friendly enough", "All very nice", and "always offering help".

During our visit we were shown the "Just a minute" cards for the ante natal ward in January 2011. These were overwhelmingly positive and included the following comments: "friendly staff", "nurses were very helpful", "I’m being well looked after", "staff were excellent, "compassionate and caring", and "staff are very kind".

We also looked at comments in the book on the postnatal ward. Comments included, "Was really pleased with my stay at Mayday – treated really good by all the staff’. "Staff were friendly and approachable and tried to help all the ward occupants". "Pleased with the midwifery team".

Croydon Health Services NHS Trust provides local services, primarily for people living in and around Croydon from the two locations, Croydon University Hospital and Purley War Memorial Hospital. The Purley Memorial hospital provides outpatient and diagnostic services only. Croydon University Hospital provides acute services to a population of 383,000.The trust also runs15 community clinics across the area.  

The trust employs approximately 3,640 staff and has a team of 300 volunteers supporting the services.

We carried out an announced inspection visit to the hospital services and community clinics between 16 and 19 June 2015. We also undertook an unannounced visit to the hospital and community clinics on 23 June 2015.  

Overall, this hospital requires improvements. 

Our key findings were as follows:

Safe 

• The trust had reported fewer incidents than other trusts of its size and some incidents may not have been reported.

• Staff were encouraged and supported to report incidents when they occurred. However, staff working in operating theatres did not always complete incident reports.
• Incidents were not always recorded and categorised as serious until after a complaint had been received.
• Investigations in the majority of instances had been undertaken in an open and transparent manner. Review processes in the surgical division did not always include adequate examination of the root causes of the incident, and did not explain the consequences in a way that relatives could understand.
• Patients were informed when a serious incident had happened and were updated on the progress of the investigation.
• The service arrangements in the Emergency Department (ED) did not always enhance patient safety. Patients who did not arrive by ambulance were not always clinically assessed as soon as they arrived. Some ED patients were sent in error to the urgent care centre following an initial assessment by staff running the adjacent urgent care centre.
• Although it had been difficult to recruit and retain nursing staff, there were adequate arrangements to ensure safe nursing staff levels.
• There were sufficient medical staff to provide safe treatment and care to patients, although the availability of surgical cover on Sundays did not support the delivery of a trauma service.
• There were arrangements to minimise risks of infections to patients, the public and staff. However, equipment used by patients had not always been cleaned to the required standards in the Emergency Department. The environment in Cardiology was not sufficiently clean or well maintained. Operating theatres were in a poor state of repair.
• Elective orthopaedic cases were nursed on the mixed surgical speciality wards, which did not reflect recommendations for delivery of safe surgical services by the Royal College of Surgeons.
• Arrangements for medicines optimisation ensured the safe and effective use of medicines for the best possible patient outcomes. However, medicine fridge temperature checks were not done regularly in some surgical areas.
• Patient risk assessments were undertaken and where patients' conditions deteriorated, their needs were responded to by appropriately skilled staff.
• Staff had access to safeguarding information and had a good awareness of this area of patient safety; however, safeguarding of vulnerable adult training was not always up to date across the various departments.
• Staff compliance with mandatory patient safety related training was often below target levels. 
• Equipment used for surgery was sometimes inadequate or unavailable.

Effective

• Where possible, staff followed best practice standards and professional guidance for clinical practice.
• There was no trauma service on a Sunday, which was not in line with Fractured Neck of Femur (NOF) guidelines.
• There was a collaborative and multidisciplinary approach to the delivery of patient treatment and care from clinical and allied healthcare professionals. The exchange of patient information was not optimised on surgical wards, where consultant ward rounds often took place without a nurse present.
• Access to services and clinical experts outside normal working hours in the main supported the effective delivery of care. 
• Patient outcomes were generally in line with or better than the national average except for emergency trauma and orthopaedic surgery. Readmissions following emergency trauma and orthopaedic surgery were worse than expected.
• Staff had access to training and opportunities to gain competencies related to their area of work.
• The assessment of patients' pain was carried out and the majority of patients reported having timely pain relief.
• The individual nutritional needs of patients in ward areas and the Emergency Department were considered and acted upon. However, there was no standardised protocol to ensure patients did not become unnecessarily dehydrated before surgery.  
• Staff sought consent from patients before undertaking treatment and care. Consent took into account the best interests of individuals who were not able to make informed decisions for themselves. However, in medical services there was a lack of assurance that capacity assessments were always being carried out when needed and consent was not always recorded in medical notes.
• There was no formal arrangement to access anaesthetic review of surgical patients at pre-assessment. Procedures were sometimes cancelled as a result of patients not having been reviewed by an anaesthetist.
• There was no agreed process for radiological investigations required by the day surgery unit.

Caring

• Staff provided physical and emotional care to patients in a kind, considerate and compassionate manner. Patients were treated with dignity and respect and were supported with their individual needs. Those people who were important to the patient were involved in their care where wished.
• The needs of patients living with dementia or having learning disabilities were considered and addressed.
• Multidisciplinary meetings included discussion of the patient’s choice and relatives' involvement when planning discharge and follow-up care arrangements.
• Patients and their families felt involved and listened to but medical patients said there was a lack of information related to their treatment. Staff respected decisions and choices, and were supportive of varying cultures, backgrounds and faiths.    

Responsive

• Services had been planned and arranged to meet the needs of the local population.
• Some patients spent too long in the Emergency Department before being admitted to a ward.
• Elderly care pathways ensured that elderly patients were assessed and supported with all their medical and social needs.
• The acute liaison nurse for patients with a learning disability worked closely with staff to improve the patient experience and the effectiveness of treatment.
• Theatres were under used and scheduling of operations was not planned to take account of demands on the day surgery unit or on the Intensive Care Unit.
• Some surgical procedures were cancelled on the day as a result of a lack of equipment availability.
• The length of time from referral to treatment for surgery was now generally in line with, or better than, the national average.
• Care pathways for surgical patients were enhanced by multidisciplinary working with specialist nurses and links with the trust community health services.
• Volunteers worked closely with staff to ensure people's needs were responded to.
• Discharge arrangements were not always efficient, with patients waiting too long in the discharge lounge and waiting too long for their prescriptions. There were blockages in the discharge of surgical patients due to lack of rehabilitation beds in the community.
• Staff understood the complaints reporting and investigation process. Work to improve the complaints management process had taken place but there remained some delays in updating people on the progress of investigations.

Well led

• The majority of clinical areas were well led, with strong and effective governance arrangements in place. There was efficient and effective leadership and teamwork in most areas. However, the clinical governance structures in surgery were weak, with a lack of reliable information about services. There was no joined up approach or standardisation across surgical services.
• Risk management, incident reporting and shared learning from these was happening across the majority of areas, with the exception of surgery. Issues affecting the smooth delivery of services or for shared learning around risks were not always discussed.
• The board meetings were not attended by surgical or medical consultants. Minutes of these meetings did not demonstrate an understanding of risks that would benefit from being shared with staff.
• Surgery services had new leadership, who recognised the need to engage staff in developing a strategy and improving services.
• Most staff said they were respected and valued by their colleagues, and that the leadership encouraged candour, openness and honesty.
• The culture in the hospital was centred on the needs and experience of people who used the service and promoted the delivery of high quality, person-centred care. However, some staff in surgical areas felt they had not been able to contribute to improvements and that concerns were not always listened to.
• Where changes happened in theatres as a result of external recommendations these had been changed by subsequent external consultation. Some changes were made without staff consultation.  
• Local initiatives to improve patient experiences and to motivate staff were taking place through ‘listening into action’.

Areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Improve clinical governance and risk management in the surgical directorate.
• Implement promptly plans to refurbish theatres and to put in place an equipment replacement programme.
• Ensure that 90% of staff receive up-to-date safeguarding and mandatory training.

In addition, the trust should:

• Ensure that mental capacity assessments are completed and that consent is recorded in patient notes.
• Continue to recruit to vacancies across all staff groups in all areas and ensure staffing levels are reviewed in line with increased demand for services
• Ensure the environment in all clinical areas complies with national guidance and promotes privacy and dignity.
• Review with staff the results of the 2014 staff survey and develop an improvement plan.
• Ensure that Emergency Department patients are assessed and treated within the nationally agreed standards by an appropriately qualified member of staff.
• Ensure that all equipment used by patients in the Emergency Department is clean.
• Fully implement the Emergency Department computer system functionality to allow contemporaneous recording of accurate patient records and patient risk assessments.
• Improve the processes for recording mortality and morbidity meetings.
• Involve all relevant staff in reviewing the scheduling of operations to maximise efficiency and improve the patient experience.
• Consider how it to make a trauma service available on Sundays.
• Ensure that all work streams in the outpatients transformation programme are completed.
• Ensure that medicines are correctly stored and are in date.
• Improve bed flow between the critical care unit and medical wards.
• Provide a specific risk register for end of life care.
• Review resources for end of life care to provide a seven day service. 
• Review how it ensures patients and their families are kept informed about their care.
• Develop a range of health-related leaflets in child-friendly formats for Children’s Services.
• Provide a fridge suitable for the storage of expressed breast milk on Rupert Bear ward.
• Ensure that the planned improvements to parent accommodation in children's services is completed on time.
• Ensure that the planned maintenance work and equipment replacement in maternity are completed in a timely fashion.
• Review midwifery staff's awareness of the action to take in the event of activity levels escalating outside normal working hours.
• Improve the experiences of women being cared for on the gynaecology ward after a pregnancy loss.
• Improve the level and range of information available to women following pregnancy loss regarding the disposal of the pregnancy remains.
• Consider how to meet its internal objectives to monitor compliance with guidelines on an annual basis.

We saw several areas of outstanding practice, including:

• The Specialist Palliative Care team had engaged with the public and staff to inform the development of the ‘care of the dying person care plan.’ This included new prescribing guidance for symptoms that occur at the end of life, as well as new medical guidance.
• The trust was involved in the LEGACY study for secondary breast cancer, in collaboration with the Royal Marsden and the Institute of Cancer Research. The objectives of the LEGACY study are to provide researchers with the best opportunity to understand secondary breast cancer, how it works and how to stop it.
• The diabetes team for children and young people was recognised for providing excellent care.
• The special care baby unit had level 2 UNICEF accredited baby-friendly status where breast feeding was actively encouraged and mothers were given every opportunity to breast feed their babies.
• The urogynaecology and pelvic floor reconstruction unit at Croydon Healthcare had an international profile in relation to research, provided courses to the obstetric community and had won many awards.
• The maternity service was currently developing and piloting a programme of antenatal courses designed to support women with limited English.

Professor Sir Mike Richards

Chief Inspector of Hospitals