The Chief Inspector of Hospitals, Professor Sir Mike Richards, has today published his report on the quality of care provided by Croydon Health Services NHS Trust at Croydon University Hospital (which many of you probably still refer to as Mayday).
The report is based on a two-day inspection by a team from the Care Quality Commission (CQC), which included doctors, nurses, hospital managers and trained members of the public, that took place during September. The team examined the care provided in A&E, medical care (including older people’s care), surgery, intensive/critical care, maternity, children’s care, end of life care and outpatients. They also visited the hospital unannounced, held focus groups with staff and a public listening event.
Croydon is one of the first hospitals in the country to go through this new, much more rigorous inspection regime which the Government asked the Care Quality Commission to introduce in the wake of what went so terribly wrong at Mid Staffordshire NHS Trust. The NHS is one of the best things about this country, but it isn’t perfect and we have a right to know how good the care at our local hospital is; the last Government was wrong to try to cover these things up.
You can read a copy of the report here.
Overall, it concludes that the new senior management team at the Trust are working hard to change its culture and, while it is early days, this seems to be having a positive impact. However, there were still areas of the hospital where care needs to be significantly improved. The inspection team found that some outpatient clinics were poorly organised and significant numbers of older people were being discharged in the evening. They were also concerned about low staffing levels affecting patient care, especially in wards for older people, and the poor physical environment in A&E and some other parts of the hospital which makes the delivery of care difficult.
The Trust has been told that it must take action to improve in the following areas as a matter of priority:
• staffing levels in older people’s wards;
• discharges in the evening, especially of older people;
• outpatients (providing enough seating; communicating better about the reasons for, and length of, delays; and reducing waiting times);
• making sure care plans involve people and reflect their needs; and
• arrangements between A&E and the Urgent Care Centre.
It also needs to improve in a number of other areas, including:
• staffing, cover and skill mix across a number of services;
• improving the quality of care delivered to patients who are not being treated in the correct ward for their condition;
• monitoring the availability of pain relief, especially for people moving between wards;
• developing a stronger attention to detail on key practices including infection control;
• improving the accuracy and storage of patient records; and
• supporting food choices for people with dementia.
Encouragingly, the report also identifies a number of areas of good practice, including:
• the ‘Listening into Action’ approach, designed to enable frontline staff to help identify improvements that could be made;
• sustained improvements in maternity services;
• the care of people with dementia in A&E;
• the new Acute Medical Unit;
• the Chronic Obstructive Pulmonary Disease (COPD) clinic, which was working well to prevent avoidable respiratory admissions; and
• the palliative care team, who carried out good joint working with a local hospice.
In the interests of transparency, here is a direct quote from the Chief Inspector:
"Whenever we inspect we will always ask the following five questions of every service:
Is it safe?
"At Croydon University Hospital, we found that while most services were being delivered safely, a number of areas needed to be improved as a matter of priority. There were staffing challenges in a number of areas of the hospital - including A&E and elderly care - despite an ongoing recruitment drive.
Is it effective?
"We found that services were largely being delivered effectively. While there was no evidence of concerns about infection rates or mortality rates, lessons learned from incidents and audits wasn’t always fully embedded at ward level.
Is it caring?
"Most people that we spoke to were positive about their care and much of the care we saw during this inspection was good. We had concerns, however, about outpatients and also about the number of people - especially the elderly - who were being discharged in the evening. This is a Trust where patient experience has been problematic in the past and some recent cases were raised at the public listening event.
Is it responsive to people’s needs?
"The hospital needs to do more to be responsive to people’s needs, especially in A&E, where large numbers of people are being discharged just before the four hour target is breached, and in appointments for orthopaedic and eye services. The physical environment especially in areas like A&E (which was crowded and badly designed) made the delivery of care difficult.
Is it well-led?
"The trust’s new senior management team has made impressive strides in the past six months in particular and staff were keen to tell us about the impact they’d made. Despite this, more evidence of sustained improvement is needed. We found that complaints were not always responded to within an appropriate timetable and some patients told us that staff were defensive when responding to their concerns."
The CQC’s findings are very much in line with my own views based on the feedback I get from constituents and I suspect won’t come as any surprise to the new senior management at the hospital. They are already taking action to tackle many of the issues the CQC has identified eg recruiting more nurses, midwives and doctors, bidding for funding to modernise A&E. Care is not consistently of the quality we have a right to expect but under the new management things are changing for the better and I am confident that when CQC inspectors return in due course to report on the Trust’s progress in making the required improvements they will like what they see.
UPDATE: Here is a response I have just received from John Goulston, the Trust's Chief Executive:
The enthusiasm and compassion of staff has been singled out for praise following the most in-depth inspection ever undertaken at Croydon University Hospital. The Care Quality Commission (CQC) acute hospital inspection report is both fair and well balanced and includes a number of areas of good practice and areas for improvement. There are nine areas of good practice and as well as positive staff attitudes, the report names the care of people with dementia in A&E and the Listening into Action engagement programme. This is a hugely encouraging assessment of our progress at the hospital after many challenges. It shows us there is still more that needs to be done and where it needs to happen. Perhaps most importantly, the inspector’s assessment echoes our own priorities for the immediate future.
The report includes three lists for action and improvement. The first is essential standards of quality and safety not being met. The four compliance actions which we must act on are care in outpatient departments; the numbers of older people discharged at night; care plans recognising people’s assessed needs and finally the care received along with staffing levels on older people’s wards. The second list names five areas where we must improve and the CQC ask for evidence of this. The final list is of eight areas where we could improve and inspectors saw changes being made to address these.
We will act on these issues through recruitment, staff engagement and the hospital’s physical environment. This will ensure we can provide safe, compassionate and excellent care and make CUH the first choice for both staff and patients. We must also insist on excellence everywhere, so that where we are getting things right, such as children’s care, surgery and helping older people in A&E, we then share and learn from each other. There are no shortcuts and whether it is recruitment and staffing or redeveloping and refurbishing where we work, this will take time. We are beginning to see the positive impact of our work so far. The CQC’s comments on maternity services are an example of how far we have come and what we can achieve.
This Government’s response to the Francis Inquiry underlines that there is no excuse for poor patient experience and that it is the responsibility of us all to listen and then act on what patients tell us. To know that the compassion and dedication of staff has been seen by more than 20 clinical leaders, patients and inspectors when they visited in September, is invaluable.
I and a number of senior colleagues met with the CQC, Croydon Clinical Commissioning Group, NHS England and the NHS Trust Development Authority earlier this week. Croydon Council and Healthwatch representatives also attended. This is a key part of the inspection process, called a Quality Summit, held to help develop and agree action plans based on the inspection team’s report. There is much still to be done to improve our services for patients but this report shows we are on the right lines.