Quality Report 2020/21 - NHS Croydon Health Services
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NHS
Croydon Health Services
NHS Trust
Quality Report
2020/21
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Quality Report 2020/21
PART 1 - Information about this Quality Report 4
Statement on quality from the Chairman and Chief Executive of Croydon Health
6
Services NHS Trust (CHS)
Executive Summary 7
Trust Objectives 8
Our Vision and Values 9
PART 2 - Priorities for improvement and statement of assurance from
12
the Trust Board
Priorities for Improvement 13
Progress against our 2020/21 Priorities 13
• Patient Safety 13
• Clinical Effectiveness 14
• Patient Experience 15
Quality Priorities for 2021/22 18
• Patient Safety 18
• Clinical Effectiveness 18
• Patient Experience 19
• Quality Improvement 19
Statements of Assurance 2020/21 22
• Review of Services 23
• Executive Structure Chart 24
• Information on Participation in National Clinical Audits (NCA) and National
25
Confidential Enquiries (NCE)
• Patient Led Assessment in the Care Environment (PLACE) Audit 25
• Participation in Clinical Research and Development 26
• Commissioning for Quality and Innovation (CQUIN) 30
• Care Quality Commission (CQC) Inspection and Quality Improvement Programme 31
• Data Quality 33
• Information Governance Assessment Report 34
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• Mortality Reviews and Learning from Deaths 35
• Clinical Standards for seven-day hospital services 40
• Health and Safety Executive Incidents 41
• Reporting against Core Indicators 42
• Staff Survey 44
• Staff and public engagement 48
PART 3 - Other Information 52
Overview of Quality Care offered by CHS 53
• Patient Safety Incidents 53
• Never Events 53
• Duty of Candour 54
• Infection Control 55
• PALS and Complaints 59
CHS Performance against relevant indicators 61
• Referral to Treatment (RTT) Waiting Times Performance 2020/21 62
• Volunteers 62
• Freedom to Speak up Guardians (FTSU) and Whistleblowing 63
• Emergency Department Performance 65
• Cancer and Macmillan 68
Annex 1 - Statements of Assurance 71
Annex 2 - Impact of the COVID-19 Pandemic on Activity 73
Annex 3 - Statements from External Stakeholders 81
Annex 4 - National and Local Clinical Audit Participation 84
Annex 5 - Glossary 87
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Quality Report 2020/21
PART 1
Information about Quality Report
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Quality Report 2020/21
What is a Quality Report?
It is an annual report that providers of NHS
healthcare services must publish to inform the
public of the quality of the services they
provide. This is so you know more about our
commitment to provide you with the best
quality healthcare services. It also encourages
us to focus on and to be completely open
about service quality and helps us develop
ways to continually improve.
Why has CHS produced a Quality Report?
CHS is statutorily required to publish a Quality Report.
This is the ninth year that we have done so; all of our
Quality Reports are published on our website:
www.croydonhealthservices.nhs.uk
What does the CHS Quality Report include?
We collect a large amount of information on the quality of
all our services within three areas defined by the
Department of Health and Social Care: patient safety,
clinical effectiveness and patient experience.
We have used this information to look at how well we have
performed over the past year (2019/20) and to identify
where we could improve next year. We have defined three
main priorities for improvement based on our Quality
Strategy 2019 to 2021.
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Quality Report 2020/21
Statement on Quality from the Chairman and Chief
Executive of Croydon Health Services NHS Trust (CHS)
A key pillar in our annual objectives, and by far involved in Croydon Quality Improvement
the most important aspect of our work is the (CQI), we’re empowering teams to take charge
delivery of high quality care for every patient in of change in their own areas.
the right place, at the right time.
To date, almost 300 staff have been trained in
The publication of our last Quality Account quality improvement and over 135 peer led
came shortly after the first wave of the COVID- improvement projects have been registered,
19 pandemic, the greatest health crisis that the which demonstrates the enthusiasm of our
NHS has ever faced. Now as we look at the colleagues to truly make Croydon the safest
publication of the 2020/21 report, we are in and most compassionate, professional and
recovery from an even more significant second respectful place for our patients to be treated
wave of the virus. and our staff to work.
Despite the events of this year, our commitment Whilst we have seen progress towards our
to the quality of care we deliver to our patients ambitious targets across all six of our quality
has never wavered. priorities, as can be expected in the cycle of
continuous improvement, there is still more for
The launch of our Patient Experience, us to do. This includes our ambition to reduce
Engagement and Involvement Strategy for the total number of falls incidents, through
2020/23 is perhaps the most exciting step initiatives like our ‘bay watch’ scheme, and the
forward in our quest to improve our care for the roll out of the Croydon Accreditation,
people of Croydon, giving us the tools to Recognition and Exemplar Scheme to all adult
harness the experiences of those we have inpatient wards, to drive quality improvement in
treated and to listen and learn from them, relation to patient safety and care.
adapting our services to the needs of patients,
relatives and local residents, in our ambition to Throughout 2020/21, the focus of our clinical
provide excellent health and care for all. teams was rightly on treating those affected by
the COVID-19 pandemic and keeping our staff
A key strand of this work is our focus on and our patients safe.
reducing health inequalities in our community.
Whilst work had already started in this area, the Now, as we look ahead to our recovery plans,
COVID-19 pandemic has demonstrated an ever we have a unique opportunity to transform our
increasing need to grow our understanding of approach to quality, embedding the actions
these issues and the steps that we need to take outlined in our priorities into the Trust’s
to tackle them, to ensure every local resident recovery plans.
receives the best possible support to stay well,
access services when they need them and have This year’s Quality Account details some of this
their voices heard. work and we are pleased to share this with you
as we continue our journey of improvement in a
While this isn’t simply a quality priority but an post-COVID world.
overarching Trust priority, our commitment to
improving the quality of demographic data we
collect to support improvements will play a vital
role in identifying trends, evidencing where
change is required and helping to develop
action plans aimed at reducing inequalities and
make the Croydon’s health and care system as Matthew Kershaw Mike Bell
inclusive and accessible as possible.
Trust Chief Executive & Chairman
We are also learning from the experiences of Place Based Leader for
our staff and the vital work of frontline teams
who deliver our services every day. With Health
marked improvements in the Trust’s annual
staff survey results and even more staff getting
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Executive Summary
All NHS Trusts are required to produce and publish an annual Quality Report setting out the quality
performance for the preceding financial year.
In this report, from page 12 onwards, we describe and our progress against our quality priorities for
2020/21 and from page 18 onwards, our key quality priorities for 2021/22. We are required to include
specific data that we have reported externally to National Bodies such as the Care Quality
Commission (CQC) and the Health and Social Care Informatics Centre and these are set out at Annex
5, page 89.
The report has been shared with Croydon Clinical Commissioning Group (CCG), Croydon Council’s
Scrutiny Heath and Social Care Sub-Committee and Healthwatch Croydon; with statements from
these groups included at Annex 3, page 82. We have explained our acronyms and terms in the main
text and there is also a full glossary at the end of the report.
Croydon is a hugely diverse borough with a growing population and we play an important role in
keeping our community well and healthy.
To ensure that this report is accurate, robust and properly reflects the services the Trust provides, it
was reviewed and approved by the Trust’s Quality and Audit Committees and the Trust Board prior to
publication.
Croydon Health Services employs more than 4,000 staff and provides integrated NHS services to care
for people at home, in schools, and health clinics across the borough, as well as at Croydon University
Hospital and Purley War Memorial Hospital.
Croydon University Hospital, in the north of the borough, provides more than 100 specialist services
and performs over 400,000 outpatient appointments every year. We also perform more than 250,000
planned procedures annually, either inpatients or day cases. The hospital is also home to the
borough’s only Emergency Department, supported by three GP hubs. It also provides 24/7 maternity
services; including a labour ward, midwifery-led birth center and the Crocus home birthing team.
Purley War Memorial Hospital (PWMH), in the south of the borough, offers outpatient care which
includes diagnostic services and physiotherapy, as well as ophthalmology services run by Moorfields
Eye Hospital, alongside an onsite GP surgery.
Our experienced district nursing teams, Allied Health Professionals (AHPs) and community matrons
look after people of all ages across Croydon, and our Children’s Hospital at Home cares for children
with long-term conditions without them having to come to hospital.
Our emergency care doctors and nurses have also teamed up with local GPs to run a seamless
network of urgent care services across the borough, including booked appointments with a GP
available seven days a week.
For more information about our services visit www.croydonhealthservices.nhs.uk
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Trust Objectives
Well led organisations have, among other attributes, a clear set of objectives that explain the priorities
for the organisation to its staff, partners and other key stakeholders.
Our objectives, detailed below, are the result of engagement with our workforce and ongoing planning
with partner organisations.
Simply put, the strategic priorities for the Trust are to:
• Improve health and reduce inequalities
• Provide high quality care
• Support our staff
• Sustainable finances
• Develop our leadership
Setting this out means our staff can understand the priorities for the Trust and importantly the role they
all play in working together to deliver excellent care for people in Croydon and help to improve the
health and wellbeing of our population.
Underpinning all of this are our Trust values that shape everything we do. Our values determine the
behaviours our colleagues can expect of each other and importantly, what our patients and local
population can expect of the Trust.
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Our Objectives
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Our Vision and Values
“Excellent care for all and helping people in Croydon live healthier lives”
Rooted in our community through our hospitals and clinics across the borough, we always strive to
provide excellent care for all.
Our local population is also growing rapidly in size. We have the youngest population of any London
borough, with almost a third of our residents aged under 25 and, at the same time, people are living
longer. Croydon is a great place to live and work, but some people in our borough face the challenges
of poverty, poor housing or other environmental factors that can contribute towards poorer health.
This means we have to do much more to prevent ill-health and help people in Croydon to stay well.
We must do this at the same time as providing rapid access to diagnostic services and medical
expertise when and where it is needed.
Collaboration is the key. Only by working well together with our partners in the borough, can we
connect the services available to give people more coordinated and person-centerd care which will
deliver real benefits for our patients and service users in the years to come.
A patient at CHS extremely pleased with her kindle to use during the pandemic;
Our senior leaders, Matthew Kershaw and Mike Bell, going round serving our colleagues hot drinks, fruit and biscuitson one of
our weekly ‘Thirst Responders’ events. Senior Leaders Caring for colleagues
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Our Values
We want local people to feel confident in our care, and for our staff to feel proud to work here. Our
values shape everything we do, every single day. They determine our behaviour and the experience of
those we look after.
We will always be Professional, Compassionate, Respectful and Safe.
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PART 2
Priorities for improvement and statement of assurance
from the Trust Board
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Priorities for Improvement
The Trust is required by the Health Care Act 2009, to submit the annual Quality Report to the Secretary
of State, through upload to the NHS website by 30th June each year.
In order to continuously improve quality and the safe and effective delivery of high quality services, the
Quality Account acts as an opportunity for us to outline our quality objectives for the coming year and
renew our progress against those we set ourselves the previous year.
The operational pressure of responding to the COVID-19 Pandemic, has impacted the ability to deliver
the Quality Priorities for the financial year 2020/21, as such;
• 7 (50%) have been fully met
• 3 (21%) have been partially met
• 4 (29%) have not been met
Those priorities which have not been fully met have been reviewed and carried over to the priorities for
2021/22.
Progress against our 2020/21 Priorities
This section demonstrates the Trust’s achievement on the quality priorities identified for 2020/21. To
provide an at a glance view of performance we are using, a colour coded system as set out below:
Patient Safety
Priority one: Continue to improve and grow our safety culture and develop a learning
organisation.
Target to be met Rag Rating Progress in 2020/21
Recording of pressure ulcers has
Implement effective systems for the monitoring,
been reviewed in the
reporting and validation of pressure ulcer data to
implementation of Datix CLOUDIQ
enable a reduction of pressure ulcers sustained
to improve the quality of data. Year
(or deteriorating) due to a lapse in patient care
to date figures are 587 against the
delivered by Croydon Health Services.
previous year of 709.
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Target to be met Rag Rating Progress in 2020/21
Croydon Accreditation,
Recognition and Exemplar
Develop ward based reporting metrics to drive
Scheme pilot has developed ward
continuous and quality improvement in
based metrics and is in place on
relation to patient safety and care.
Wandle 2, Purley 1 and Queens 2.
Priority Two: Ensure the level of preventable harm remains below the 5% national average.
Target to be met Rag Rating Progress in 2020/21
To ensure that our Year to Date (YTD) internal The YTD 20/21 figure was 73.99%
reporting of harm free care remains at or above against the previous YTD of 75%
95%. 19/20.
Clinical Effectiveness
Priority Three: Deliver a programme of quality improvement within the Trust and wider health
and care system.
Target to be met Rag Rating Progress in 2020/21
Implement and deliver a programme of quality
improvement using Continuous Quality 135 Registered projects and
Improvement (CQI) methodology, ensuring all moving to an online register to
quality improvement projects are registered, enable improved visibility of
monitored and reported in line with the Terms of projects.
Reference.
Deliver quality improvement training to staff in the YTD 282 people have received
wider health and care system, utilising CQI some form of CQI methodology
methodology. training.
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Priority Four: Improve how we provide and evidence delivery of high quality care in
accordance with best practice and nationally recognised outcomes across our services.
Target to be met Rag Rating Progress in 2020/21
Implementation of applicable NICE guideline By end of March 2021, 209
recommendations. guidelines were received from
NICE of which 174 were
completed, 21 were overdue and
14 were in progress.
National audit. To date there have been 64
eligible national audits which we
have completed or are on track to
complete. There have been 32
national outcome reports,
however, a number of these
remain outstanding.
Patient Experience
Priority Five: Achieve and sustain improvement in patient as well as staff engagement and
experience
Target to be met Rag Rating Progress in 2020/21
Patient Experience, Engagement
and Involvement Strategy
Implementation of the Patient Experience, Approved and being delivered in
Engagement and Involvement Strategy 2020-23 in line with plan. Will be monitored
line with the delivery plan. through Patient Experience,
Engagement and Involvement
Group and Integrated Quality
Assurance Group.
The Trust’s staff engagement plan
was developed in August 2019 and
since then there has been
continued progress:
More staff completed the
Progress and implementation of the Trust Staff annual staff survey with early
Engagement Plan. results showing
improvements in
communication between
senior staff and their teams
and leadership visibility (see
page 44).
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Target to be met Rag Rating Progress in 2020/21
• We have increased our support
for the Trust’s staff network
forums to celebrate diversity and
inclusion within the Trust, with
events for disabilities and Black
History Month
• To keep staff informed
throughout the COVID-19
pandemic, we have increased
the pace of internal
communications. An average of
200 staff attend our twice weekly
webinars to hear the latest
headlines and have questions
answered from the Trust
executive and clinical leaders
alongside weekly email briefings
and a CEO blog to give a direct
line and a view from Matthew.
• We have also increased our
mental health and wellbeing
support for staff during COVID-
with 1-2-1 staff counselling,
‘wobble rooms’ so that staff can
escape the pressure for a
moment and lifestyle support,
including food deliveries.
• To increase reward and
recognition for staff, the
MyLifestyle portal was launched
in Nov 2019 offering deals and
discounts for NHS
• However, PDR rates have fallen
during the pandemic and other
projects including mentoring to
support career development had
to be paused due to the COVID
response. These and other
priorities in our engagement
plan will now be restarted
Surveys have been developed and
Develop and implement a complainant survey to
the first sets of surveys were sent
understand and learn from the experience of our
out in December 2020. The
patients, their families and carers given cause to
response has been poor and more
complaint.
work is required in this field.
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Target to be met Rag Rating Progress in 2020/21
FFT was placed on hold nationally
Improve Friends and Family Test (FFT) response from April to November 2020, as
and recommendation rates. such there has not been data to
support improvement work. Work
is underway to re-procure our FFT
provider, and with a specification
which will support mix modality
collection of data to improve
response rates.
Priority Six: Continuously improve performance against mandatory NHS constitutional
standards including CQC regulations.
Target to be met Rag Rating Progress in 2020/21
Deliver the actions within the Quality
63% of actions identified year to
Improvement Plan in line with the agreed
date have been completed and
implementation timescales for CQC ‘must do’ and
closed.
‘should do’ actions.
Year to date response rate is 34%
against the previous year of
30.51%. This is likely in part due to
impacts of COVID-19. The Patient
Ensure 95% of complaints receive a response
Experience team has been
within the agreed timescales
restructured to support case
working and increase support to
directorates in responding to and
managing complaints.
Reduce the number of complainants who remain Year to date there are 57 re-
unsatisfied with their complaint response resulting opened complaints compared to
in re-opened complaints. 59 for the previous year.
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Quality Priorities for 2021/22
The following priorities are recommended for 2021/22:
Patient Safety
Priority One: Continue to improve and grow our safety culture and develop a learning
organisation.
Action Comment
Reduce the number of open action plans and actions relating to internal New action for 21/22
and serious incident root cause analysis investigations
Reduce the total number of falls incidents, with a focus on reducing New action for 21/22
unwitnessed falls
Reduce healthcare acquired infections including nosocomial COVID New action for 21/22
infection, MRSA, C. Diff
Improve the recording of demographic information for patient incidents New action for 21/22
reported
Priority Two: Ensure the level of preventable harm remains below the 5% national average.
Action Comment
Improve harm free care ratios toward the year to date (YTD) target of Previous action not
95%, with a minimum of 80% achieved. achieved in 20/21 - carried
over and amended
Clinical Effectiveness
Priority Three: Improve how we provide and evidence delivery of high quality care in
accordance with best practice and nationally recognised outcomes across our services.
Action Comment
Reduce the number of NICE guidelines overdue for review to below Previous action not
80%. achieved in 20/21 - carried
over and amended
Increase the number of Fully Compliant NICE guidelines to above 95%. Previous action not
achieved in 20/21 - carried
over and amended
Improve the systems for registering and managing internal audits with New action for 21/22
the deployment of Datix CLOUDIQ
.
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Patient Experience
Priority Four: Achieve and sustain improvement in patient as well as staff engagement and
experience.
Action Comment
Continue to deliver the Patient Experience, Engagement and Continued from 20/21
Involvement Strategy 2020-23 as per the delivery plan.
Continued from 20/21 with
Reduce the number of complainants who remain dissatisfied with their
an a new target of 5% or
complaint response, reducing re-opened complaints to below 5% of
less
total complaints.
Improve the recording of demographic information for complainants and New action for 21/22
the subject of complaints.
Previous action not
Improve response rates toward the year to date (YTD) target of 95%
achieved in 20/21 - carried
with a minimum of 80% achieved.
over and amended
Not achieved in 20/21 and
Improve Friends and Family Test (FFT) response and recommendation
carried over
rates.
Quality Improvement
Priority Five: Continuously improve performance against mandatory NHS constitutional
standards including CQC regulations.
Action Comment
Roll out the Croydon Accreditation, Recognition and Exemplar Scheme New action for 21/22
to all adult in-patient wards and complete accreditation processes for at
all wards
Deliver the actions within the Quality Improvement Plan in line with the Continued from 20/21
agreed implementation timescales for CQC ‘must do’ and ‘should do’
actions.
Priority Six: Deliver a programme of quality improvement within the Trust and wider health
and care system.
Action Comment
Develop and implement a quality improvement strategy. New action for 21/22
Deliver quality improvement training to staff in the wider health and Continued from 20/21
care system, utilising CQI methodology.
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Achievements in Quality
CHS specialist midwife for CHS deputy general manager
Dr Nnenna Osuji, Medical vulnerable and marginalized for therapies, Dee Kapfunde,
Director at CHS has been women Memuna Sowe was has been shortlisted in the
selected as one of London’s one of the four midwives National Health and Care
most inspiring black leaders, as chosen from London to meet BAME awards in the Inspiring
part of the NHS Black History the Prime Minster as part of Diversity and Inclusion Lead –
Month celebration the NHS Black History Month Role model category.
celebration
CHS respiratory, nursing and CHS has been shortlisted for a
critical care outreach team Patient Safety Award for
has been shortlisted for the CHS and the borough’s GP lead, innovative “Star Trek” tech
2021 Excellence in Patient Dr Agnelo Fernandes, was instrumental in early
Care Awards to recognise presented with “Grand Saviours pandemic in the annual HSJ
and reward dedication to Award” for our compassion and Awards, which recognizes the
healthcare during times of outstanding services during outstanding contributions of
exceptional crisis or an COVID-19 pandemic. health and social care
emergency incident. organisations across the
country.
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Achievements in Quality
Christina Clynes Our Head of
Communications and Fundraising Dr Mayank Agarwal was
was awarded Outstanding Young named the nation’s “Top
Dr. Linda Vaccari and her Communicator at the CIPR Doc” in The Sun’s “Hail
team at CHS awarded the Excellence awards. Your Heroes” awards for
“The Most Publishable Work” helping CHS to safely care
presentation Award at the 5th Throughout the pandemic and
for thousands of people
joint conference of the British beyond, the Trust’s incredible
needing emergency
HIV Association (BHIVA) and communications team has been
treatment during the
the British Association for working solidly to keep Croydon
COVID-19 crisis.
Sexual Health & HIV (BASHH) safely and successfully in the
headlines and they kept staff
informed through twice-weekly
webinars.
CHS Infection Control Lead, CHS ward sister, Nichole Team Croydon was
Juliana Kotey, was one of the Beason, was one of the two of recognized and highly
two of only 20 healthcare only 20 healthcare staff
staff selected from across the praised for Patient Safety
selected from across the and for ground-breaking
country to be invited by the country to be invited by the Croydon partnership and
Prime Minister to personally Prime Minister to personally
thank her for her exceptional support with the
thank her for her exceptional OneCroydon Alliance at
contribution during the contribution during the the annual HSJ Awards
pandemic. pandemic
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Statements of Assurance 2020/21
This section comprises the following:
• Review of our services
• Executive structure chart
• Information on participation in National Clinical Audits (NCA) and National
Confidential Enquiries (NCE)
• Patient Led Assessment in the Care Environment (PLACE) Audit
• Participation in clinical research and development
• Commissioning for Quality and Innovation (CQUIN)
• Care Quality Commission (CQC) Performance
• Data Quality
• Information Governance Assessment Report
• Learning from Deaths
• Clinical Standards for seven-day hospital services
• Health and Safety Executive Incidents
• Reporting against core indicators
• Staff survey
• Staff and Public engagement
Team Croydon was highly commended in 2 out of 3 HSJ awards for patient safety and joining up health
& care through the One Croydon alliance
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Review of Services
Throughout 2020/21 we have been privileged to continue to provide services to the people of
Croydon, whether in their own home, at one of our community facilities, or at one of our
hospitals.
Activity for 2020/21 Q1 Q2 Q3 Q4 TOTAL
Planned Care - Outpatient Appointments 87,821 122,430 134,421 137,052 481,724
Planned Care - Inpatients 64 590 736 423 1,813
Planned Care - Day cases 1,322 5,101 6,649 6,108 19,180
Maternity - Deliveries 918 887 789 783 3,377
Maternity - Babies Born (includes multiple 896 867 769 777 3,309
births)
Maternity - Home Births 2 11 9 12 34
Emergency Attendances - Main ED & UTC 21,563 29,146 27,901 25,661 104,271
Emergency Attendances - GP hubs 6,668 12,491 13,039 12,852 45,050
Emergency Admissions 28,231 41,637 40,940 38,513 149,321
Ambulance Arrivals 7,200 8,391 8,049 7,429 31,069
Occupied Bed days (General & Acute) 29,111 34,801 37,679 38,204 139,795
Beds Open 35,263 37,223 39,464 39,891 151,841
Bed Occupancy 82.55% 93.49% 95.48% 95.77% 91.82%
There are three Clinical Directorates within the Trust and each Directorate reviews service provision
through Quarterly Quality and Performance meetings with the Chief Operating Officer and reports to
the Quality Committee, monthly Quality Boards and Clinical Governance meetings.
The Trust reviews quality indicators using a monthly integrated quality & performance dashboard
(IQPR) and reports so that performance can be analysed on a monthly basis. This enables services to
identify priorities and actions needed to deliver improvements and highlight areas that are performing
well.
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Executive Structure Chart
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Information on Participation in National Clinical Audits (NCA) and
National Confidential Enquiries (NCE)
The Trust’s participation in National Clinical Audits and National Confidential Enquiries enables us to
benchmark the quality of the services that we provide against other NHS Trusts. It also highlights best
practice in providing high quality patient care and drives continuous improvement across our services.
Local clinical audits are selected on the basis of national requirements, commissioning requirements
and local evidence that has emerged from themes from incidents or complaints.
During 2020/21 The Trust participated in 64 national clinical audits. All of the national audits were in
the NHS England Quality Report listed audits that the Trust was eligible to participate in.
The list of national audit reports reviewed and a summary of some of the key actions planned or
undertaken are detailed in Annex 4 (page 85).
The National Clinical Audits and National Confidential Enquiries that the Trust participated in, and for
which data collection was completed during 2019/20, are listed in Annex 4. Also included are the
number of cases submitted to each audit or enquiry as a percentage of the number of registered cases
required by each audit or enquiry. Some areas have been marked as ‘in progress’ which means that
the data is currently being submitted, including data gathered during the period of 2019/20.
Patient Led Assessment in the Care Environment (PLACE) Audit
The PLACE programme was initially deferred at the beginning of the COVID-19 pandemic. Subsequent
guidance issued on 10/09/2020 by NHS England confirmed that the regular national PLACE collection
would not be going ahead in 2020, given the risk to patient assessors and staff in undertaking the full
assessment programme while the Covid-19 pandemic continued. Latest update to confirm this period
of pause still in place was received 26/03/2021
NHS Digital is considering a number of adjustments to the programme which may facilitate some form
of national assessment but given the huge amount of present uncertainty and pressures on the NHS,
this is being kept under review for the time being.
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Participation in Clinical Research and Development
Clinical Research Participation 2020/21
The past year has proven to be difficult for has also come to the forefront: helping to explore
healthcare as well as for research. This was the why certain ethnic groups and certain members
direct result of many of our staff absent, either of those groups have more severe illness
due to being ill with COVID, or being placed into compared to others: so far 7 gene regions have
shielding, or being redeployed to take care of been identified, with 2 leading to the development
COVID patients. This affected the continuation of of tailored therapies entering clinical trials.
research studies being carried out at the Trust,
as trials offices and the Trust were locked down
and management of studies was very limited. It
led to the start of the NIHR pause for all clinical
research, and the adoption of the urgent public
health studies into COVID.
That said, it enabled us to highlight the
importance of the role research has in improving
healthcare and patient outcomes even within a
pandemic. There were many unknowns as to
how the COVID virus acted and how best to treat
Thepart
patients with this illness. The Trust has taken PLACE programme was initially deferred at the
in a series of studies investigating beginningthese CHSofDr. Ashok
the were
COVID pandemic
on BBC London TV newsthentalking
on about
the
unknowns: RECOVERY1, REMAP CAP2, 10/09/2020 NHS England confirmed Genomics that the regular
ISARIC3, SIREN4 and GENOMICCs project5. national This
PLACE collection
year would not
we recruited 1,172 be participants
going aheadinto in
From the data obtained by Croydon and2020. other Given the risk
research to patient
studies, this wasassessors
a rise ofand40.6%stafffrom
in
Trusts, a vast amount of data was collected on last year.
undertaking Theassessment
the full COVID studies contributed
programme while54.9%the
potential treatments of patients. ThisCovid-19 has (644/1,172) of recruits. From our current
pandemic continued. Latest update to confirm National
provided a significant improvement in outcomes, Institute
this period of pausefor still
Health Research
in place received(NIHR) portfolio,
26/03/2021.
as well as reflecting on what does not work, and there was a drop in recruitment due to the
resources could be redirected to more useful suspension of studies for a several months and
NHS Digital
therapies. The initial research data highlighted is considering
restrictions on patienta number
flow of adjustments
into the hospital. to
the effect of corticosteroids, Remdesivir and These studies contributed 528 recruits (45.1%ofof
the programme which may facilitate some form
Tocilizumab having a significant contributionnational
to ourassessment but givenAthe
total recruitment). largehuge amount
majority of
of the
improving patients’ recovery and reducing present uncertainty
the year’s and was
recruits pressures
due on to the
a NHS,
large this
scale is
severity of disease. It also highlightedbeing thatkept under review
Radiology for thetrial
research time being.
(MIDI6) with 398
hydroxychloroquine and convalescent plasma recruits.
had limited effectiveness in the treatment of
COVID. These results, therefore, steered the
treatment of COVID patients and has reduced the
pressures on the NHS due to less people
requiring long term admission to hospital. The
studies conducted have also shown the
effectiveness of the vaccines at reducing the
spread of the virus and severity of the infection.
These studies are still ongoing and studies such
as the SIREN trial will further examine the long
term effects on participants that had COVID
infection or were vaccinated and monitor the
chances of re-infection. The GENOMICCs project
Comparing monthly recruitment into research trials in 2020/21
with 2019/20
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on resuming the NIHR portfolio studies, as part
of the restart program, that were suspended and
plan for how to approach recruitment of
participants with the new normal that we face,
with increasing virtual appointments and
reduction in face to face contacts. To date, only
2 projects have not restarted and formal closure
of these 2 projects is expected, as a direct result
of the effect of COVID on the trial management.
We have also had a significant uplift to our CRN
funding of almost 13.5% for the coming year.
Top recruiting research studies in 2021/22
In 2020-21, 67 research studies were being
conducted at the Trust; of which, 43 studies Terms in graph:
were supported by the NIHR, with 30 concluding
recruitment by 31st March 2021. 75% of NIHR WILL: When to Induce Labour to Limit risk in
portfolio studies concluded with their target pregnancy hypertension
recruitment achieved. Over the course of the
year. 22 studies were approved, of which 50% REMAP CAP: A Randomised, Embedded, Multi-
were NIHR portfolio badged. factorial, Adaptive Platform Trial for Community-
Acquired
69 clinical staff members participated in
research approved by the Research Ethics TRUENTH Global registry: An international registry
Committee at Croydon University Hospital for men with prostate cancer
during 2020-21. These covered over 18 different
research specialties. OPTIMISE II: Optimisation of Peri-operative
CardIovascular Management to Improve Surgical
We are 8 months into an EU funded research outcome II
project (HEIR) working with 17 partners spread
over 10 countries. The project aims to develop a PANCOVID: Pregnancy And Neonatal outcomes for
cybersecurity platform to help protect healthcare women with COVID-19
data and computer infrastructure from intrusion
and malware. GenOMICC: Genetics Of Mortality In Critical Care
We are also submitted for an NIHR grant looking RECOVERY: Randomised Evaluation of COVID-19
at management of heart failure (Safe study) as Therapy
well as working with Kingston University in one
Innovate approved study (5G Connect ISARIC: International Severe Acute Respiratory and
ambulance). A further 2 more grant submissions Emerging Infection Consortium
are in progress.
SIREN: Sarscov2 Immunity & Reinfection Evaluation
In the last 3 years, 47 publications have resulted
from our involvement in Research. Of these 29 MIDI: MR Imaging Abnormality Deep Learning
articles originated from studies that were Identification
supported by NIHR.
As the COVID outbreak eases, we will be
vigilant to see if the infection returns and will
continue recruiting into the current COVID
studies, as well as look to open Long COVID
studies that examine the health of post COVID
infection patients. In the meantime, we will focus
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CHS Learning and Development Program 2020/21
Statutory and Mandatory Kickstart Programme®
Wider Training offer
training
With the start of the pandemic Outside of our statutory and Following the introduction of the
we quickly followed national mandatory training core skills Kickstart scheme by the
guidance and stood down our requirements we have also government in 2020 CHS signed
face to face core skills offer to a offered a range of courses up and promoted this across the
predominately virtually delivered available to all. The majority of Trust in December 2020. The
programme, including our these have been delivered original intention was to partner
corporate induction. This virtual virtually or through self-learning with Croydon Council to support
programme has been running methods. The offer has included individuals through the scheme
successfully over the past year a number of webinars that NHS but local changes saw the
with the only training modules Elect have offered on team withdrawal of the Council and
remaining face to face being our leadership and resilience the Trust meeting with Croydon
practical manual handling and life specifically aimed at supporting College as an alternative
support skills courses for our through the pandemic, and some provider. Desire to support
clinical staff. By end March 2021 Mental Health First Aid courses remains fairly low across the
compliance achieved stood at provided through MHFA London. Trust as other priorities have
73% against a target of 95%. Where possible the L&OD team taken over but we remain
have continued to support local committed to supporting this
level teams with bespoke scheme in the future with a more
interventions like 360-degree joined up approach to the
feedback, coaching, reverse opportunities we can offer
mentoring and our customer through our recruitment planning
service programme “Be the cycles.
difference”. Virtual sessions on
effective appraisals and
performance management have
been made available using the
national e-learning offer. The
only courses run previously that
we have temporarily stood down
due to the pandemic were the
bespoke HR led courses as these
do not lend themselves easily to
a virtual environment due to the
practical nature of the content. In
accordance with national
guidance all non-mandatory and
statutory trainings were stopped
and have not moved to on-line.
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Lev Team /
Apprenticeship Programme Name of apprenticeship Number
el Department
Pharmacy Services Assistant 2 Pharmacy Team 1
Business Admin 3 Cancer Services 1
Installation electrician / Engineering
maintenance electrician 3 Maintenance 1
Pharmacy Technician 3 Pharmacy Team 2
Science Manufacturing
Technician 3 Pharmacy Team 1
Team Leader / Supervisor, 3 various
Over the past year we have grown the
number of individuals completing an Level 3 3
active apprentice programme from 21 to Cyber security technologist 4 ICT 1
59 individuals Trust wide, a 281%
Data Analyst 4 Patient Safety 1
increase. These individuals are spread
across a number of programmes and Ward - Rupert
levels and teams as seen from the details Health Play Specialist 5 Bear 1
on the table. For us to maximise our
Nursing Associate (NMC
annual levy pot our aspiration is to
achieve c83 people on a programme at 2018) 5 Nursing 6
any one time. As part of our plans for Nursing Associate 5 Nursing 24
2021-2022 we are developing career Operations or Departmental 5 Pod 2 -
programmes that support a wider range Manager Respiratory &
of apprenticeships at all levels and will be
Neurology/Elderly
setting a set of recruitment principles to
support managers to identify where roles Care
2
can be converted to allow us to adopt
Annex 21 principles by recruiting brand Clinical
new, external apprentices to the Trust, as Academic Professional 7 Applications 1
well as continuing to offer additional Senior Leader Master's
opportunities to our existing colleagues. Degree Apprenticeship MBA
or MSc 7 Various 14
Total 59
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Commissioning for Quality and Innovation (CQUIN)
National Health Commissioners hold a budget for the Croydon population to spend on health care
services in both the hospital and community setting, e.g. services provided by Croydon Health Services
NHS Trust. A proportion of this budget each year is reliant on the Trust meeting annual improvement
goals set by Croydon Clinical Commissioning Group and NHS England. This system is called the
Commissioning for Quality and Innovation (CQUIN) payment framework. The aims of the CQUIN goals
are to achieve improvements in quality and innovation which will support health gains for patients and
staff.
As a result of the COVID19 pandemic, there have been no reporting requirements against the CQUIN
indicator specifications, with 100% income being allocated to all Trusts. Even though there has been no
requirement to report on the above CQUINS, the Trust has Leads identified for each of the indicators
and work has been ongoing to meet targets.
The National CQUINS for 2020/2021 are listed below, but were suspended for the entire period April
2020 to March 2021:
• Appropriate antibiotic prescribing for UTI in adults aged 16+ - Achieving 60% of all antibiotic
prescriptions for UTI in patients aged 16+ years that meet NICE guidance for diagnosis and
treatment
• Cirrhosis and fibrosis tests for alcohol dependent patients - Achieving 35% of all unique
inpatients (with at least one-night stay) with a primary or secondary diagnosis of alcohol
dependence who have an order or referral for a test to diagnose cirrhosis or advanced liver
fibrosis
• Staff flu vaccinations - Achieving an 90% uptake of flu vaccinations by frontline staff with
patient contact
• Recording of NEWS2 score, escalation time and response time for unplanned critical care
admissions - Achieving 60% of all unplanned critical care unit admissions from non-critical
care wards of patients aged 18+, having a NEWS2 score, time of escalation (T0) and time
of clinical response (T1) recorded
• Screening and treatment of iron deficiency anemia in patients listed for major elective blood
loss surgery - Ensuring that 60% of major elective blood loss surgery patients are treated in
line with NICE Guideline NG24
• Treatment of community acquired pneumonia in line with BTS care bundle - Achieving 70%
of patients with confirmed community acquired pneumonia to be managed in concordance
with relevant steps of BTS CAP Care Bundle
• Rapid rule out protocol for ED patients with suspected acute myocardial infarction
(excluding STEMI) - Achieving 60% of Emergency Department (ED) admissions with
suspected acute myocardial infarction for whom two high-sensitivity troponin tests have
been carried out in line with NICE recommendations
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Care Quality Commission (CQC)
Inspection and Improvements Put into Place
The focus of CQC inspections is the experiences people have when they receive care and the impact
the care has on their health and wellbeing.
The last CQC inspection completed in the Trust found that all areas required improvement as can be
seen in the table below. An additional Ionising Radiation (Medical Exposure) Regulations (IR(ME)R)
improvement notice on Croydon Health Service radiology department was served.
Core service Safe Responsive Overall core
Effective domain Caring domain Well led domain
inspected domain domain service rating
Requires Requires Requires Requires Requires
Inadequate
Urgent & emergency improvement improvement improvement improvement improvement
↓↓
services →← ↓ ↓ ↓ ↓
Feb 2020
Feb 2020 Feb 2020 Feb 2020 Feb 2020 Feb 2020
Requires Requires Requires Requires Requires Requires
Medical care (inc. improvement improvement improvement improvement improvement improvement
older people’s care →← ↓ ↓ →← →← →←
Feb 2020 Feb 2020 Feb 2020 Feb 2020 Feb 2020 Feb 2020
Requires
Good Good Good Good Good
Surgery improvement
Feb 2018 Feb 2018 Feb 2018 Feb 2018 Feb 2018
Feb 2018
Requires
Good Good Good Good Good
improvement
Critical care ↑ ↑ ↑ ↑↑ ↑
→←
Feb 2020 Feb 2020 Feb 2020 Feb 2020 Feb 2020
Feb 2020
Requires
Good Good Good Good Good
Maternity improvement
Oct 2015 Oct 2015 Oct 2015 Oct 2015 Oct 2015
Oct 2015
Requires
Services for children Good Good Good Good Good
improvement
& young people Oct 2015 Oct 2015 Oct 2015 Oct 2015 Oct 2015
Oct 2015
Requires
Good Good Good Good Good
End of life care improvement
Feb 2018 Feb 2018 Feb 2018 Feb 2018 Feb 2018
Feb 2018
Requires
Good Good Good Good
Outpatients N/A improvement
Feb 2018 Feb 2018 Feb 2018 Feb 2018
Feb 2018
Requires Requires
Requires
Good Good improvement improvement
Diagnostics improvement N/A
Feb 2020 Feb 2020 Feb 2020 Feb 2020
Feb 2020
Requires Good Good Requires Requires Requires
improvement Sep 2018 Sep 2018 improvement improvement improvement
Community - adults
Sep 2018 Sep 2018 Sep 2018 Sep 2018
Requires Requires Good Requires Requires Requires
Community –
Improvement improvement Sep 2018 Improvement improvement improvement
children & young
Sep 2018 Sep 2018 Sep 2018 Sep 2018 Sep 2018
people
Requires Requires Requires Requires Requires Requires
improvement improvement improvement improvement improvement improvement
Overall Trust rating →← →← ↓ →← →← →←
Feb 2020 Feb 2020 Feb 2020 Feb 2020 Feb 2020 Feb 2020
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Following the findings of the CQC inspection complied with. These visits also improve local
Croydon Health Services put in place the Quality service provision, understanding and offer
Improvement Programme to actively monitor and opportunities to discuss service developments.
put in place changes for improvement.
On visiting a ward for an internal assurance visit
A total of 343 actions were highlighted by the CQC the panel are looking for the following Key Lines of
report for the Trust to improve services. Of the Enquiry (KLoE):
initial 343 action 154 have been completed and are
having a positive impact on the quality of services • Incidents
provided by Croydon Health Services. The • Safeguarding
remaining 189 actions are progressing with regular • Patient Risk
meetings to ensure that these are completed. • Patient Flow
• Staff Levels (Nursing and Medical)
• Staff training and education
Status of actions following CQC
• Medication
Inspection 2019-20
• Records
• Infection Control
Must do
• Environment & Equipment
0 20 40 60 80 100 120
• Evidence based care and treatment
Number of CQC Actions and patient outcomes
• Nutrition
Progressing Completed
• Pain Relief
Progres • Compassionate care
Completed
sing • Consent, Mental Capacity Act and
72 DOLs
Must Do • Service delivery to meet the needs of
(20.9% of total local people
An essential change actions) 87
that needs to be made • Learning from complaints and
(45% of the concerns
to better patient
outcomes total must do • Governance, risk management and
actions) quality measurement
Should Do 82 IRMER Improvement Notice
Suggested (23% of total Croydon Health Services (CHS) NHS Trust
improvements to be actions) received an IRMER Improvement Notice on 9th
made in order to offer 102 October 2019. Immediate remedial actions were
(44.5% of the taken by CHS.
the best experience
and health outcomes total should do An IRMER inspector closer letter was received on
of patients. actions) 12th May 2020, with the recommendation that the
IRMER inspector would be taking a closer look at:
Internal Assurance Visit • Compliance arrangements in Cardiac
Catheter Laboratory
Internal Assurance Visits have been undertaken by • Optimisation of patient radiation dose
the Trust as part of a rolling internal quality levels
assurance programme to assess the core services, • Optimisation of patient radiation dose
as defined by the Care Quality Commission levels
(CQC). The purpose of quality assurance visits is • Introduction of x-ray equipment quality
to assure that all fundamental standards are being assurance programme
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Improvements in radiation safety continue Trust-wide, both within the Radiology Department and in
other areas e.g. Cardiology. This is demonstrated by staff receiving additional radiation safety training,
updating procedural documentation and auditing radiation doses.
The Radiology Department does recognise that there are still areas where more work is required,
however, with the assistance of the Medical Physics Team there is a robust governance process
within the Radiology Department that supports a continuous improvement programme.
The Radiology Department would like to acknowledge that appropriate actions are being agreed and
delivered at Trust board level e.g. x-ray equipment replacement programme.
The Radiology Management Team would like to provide reassurance to the Trust from this report that
safe practices of ionising radiations are being carried out to ensure patient, general public and staff
safety by local compliance with the statutory requirement of Ionising Radiations Regulations (2017)
and Ionising Radiation (Medial Exposure) Regulations 2017.
Data Quality
The trust is focused on improving the quality of our data. High quality, timely data is essential to
support decision making within the organisation, whether that be clinically or corporately. In 2020/21,
the trust has focused on the improvement of data quality, with the Data Quality Improvement Group
initiated in Q4 to provide oversight and coordination of data quality improvement work.
The below indicates the Trust’s position against the Data Quality Maturity Index (DQMI). The DQMI is
published by NHS Digital and provides healthcare data submitters with timely and transparent
information about their data quality. It is a data quality value index based on the completeness, validity,
default values and coverage of core data items. These include NHS number, date of birth, gender,
postcode, specialty and consultant.
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Information Governance Assessment Report
Data Security and Protection Toolkit the Trust in response to the incident.
(DSPT) 3. The third incident was due to a system
change that exposed certain test results to
Annually the Trust completes the Data Security staff at the Trust who would not normally have
and Protection toolkit, an online self-assessment access to those particular test results. Whilst
of its performance against the national data there was no record of inappropriate access
security standards. The Trust submitted a the test results should not have been
comprehensive improvement plan in September available on the system. The weakness has
2020 to support the annual toolkit submission (as been addressed through technical changes
it has done in previous years), however, the Trust and the risk eliminated. The ICO took no
was awarded ‘standards not met’ due to the action against the Trust.
number of elements that remained to be 4. The fourth incident resulted from a former
completed to achieve full compliance. The Trust member of staff at the Trust, who claimed to
will continue to be transparent and detailed in its have access to patient contact details despite
toolkit submission and is committed to obtaining a having left the Trust. The staff member
high standard of compliance on its journey to full subsequently confirmed that they did not
compliance at standards met. The Trust unlawfully retain any patient information and
anticipates achieving a similar result in the the ICO took no action against the Trust as a
forthcoming submission in June 2021, namely result of this incident.
‘standards not met’. The aim is to achieve
standards not met ‘plan approved’ the following The Trust continues to monitor, improve and
year and full compliance the year after. implement advice and lessons learned from
reported breaches and incidents. The intention is
Reported Data Protection and Security to minimise the occurrence of similar repeated
Incidents incidents and reduce the impact and likelihood of
serious incidents.
The Trust continues to promote and encourage
data protection incident reporting to support and Freedom of Information Act (FOIA)
build secure systems and processes. The Trust Requests
self-reports breaches categorised as potentially
capable of causing harm (level 2 incidents) to The Trust’s compliance rate measured by the
NHS digital using the Data Security and percentage of requests completed within twenty
Protection toolkit reporting facility. The total calendar days (as required by the Freedom of
number of incidents reported for the year is eight. Information Act) was 68% for the year (April 2020
to March 2021). This represents a decrease of
Four of these incidents were identified as 11% on the previous year. The number of
breaches that met the threshold for notifying to the requests received decreased by 111 from the
Information Commissioner Office (ICO) as previous year representing a decrease of 16%.
follows:
Subject Access Requests
1. Personal information was sent to an incorrect
email account in error. The ICO took no The Trust continues to respond to individuals’
further action. The Trust identified the root requests for their health records. The compliance
causes of the error and took steps to raise rate measured by the percentage of requests
staff knowledge and understanding to completed within the statutory time frame was
minimise the risk of similar incidents. Actions 98% for the year. The number of requests
taken included updates to policies and received was 2348 which was slightly lower (less
relevant communications on best practice. than 1%) than the number of requests received in
2. The second incident was due to the previous year.
misinformation being received from another
organisation resulting in the Trust legitimately
sharing a residential address causing
unintended safeguarding concerns. These
concerns were appropriately addressed at the
time by the organisations involved and no
action was taken by the ICO which was
satisfied with the remedial actions taken by
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