Croydon Health Services NHS Trust has presented its Quality Account for 2024-25 to the Scrutiny Health & Social Care Sub-Committee, highlighting key performance areas and future priorities. The CHS Quality Account details the Trust's activity in 2024/2025.
The Quality Account is a statutory annual report reflecting the trust's performance in patient safety, clinical effectiveness, patient experience, and leadership. It provides transparency and supports continuous improvement in healthcare quality for Croydon residents.
The report includes a review of performance in 2024/25 and priorities for improvement in 2025/26. Key areas covered are:
- Patient Advice & Liaison Service (PALS)
- Complaints & PALS Themes
- Care Environment
- Overview of Clinical effectiveness
- Mortality Reviews and Learning from Deaths
- Learning Disability Deaths
- Clinical Standards for seven-day hospital service
- WELL-LED
- Well-Led review
- Risk Management
- Quality Improvement
- The National staff Survey
- Staff Wellbeing & Staff engagement
- Quality Priorities for Improvement 2025/26
- Statements of Assurance 2024/25
- Review of Services
- Information on Participation in National Clinical Audits (NCA) and National Confidential Enquiries (NCE)
- Commissioning for Quality and Innovation (CQUIN)
- Care Quality Commission (CQC) Inspection
- Information Governance Assessment
- Reported Data Protection and Security Incidents
- Freedom of Information Act (FOIA)
- Subject Access Requests
- Operational Performance as a Quality Indicator
- Our Approach to Population Health Management, Prevent III-Health, and Health Inequalities 2024/2025
- Mental Health Services
- Digital Services development (Information & Communication Technology
- Croydon Health Charity
- Chaplaincy & Spiritual Care
- Statements from external stakeholders
Key achievements highlighted in the report include improvements in the Cancer Faster Diagnosis Standard (FDS), where the trust ranked best in London and second nationally, and the implementation of the Call for Concern
service, aligning with Martha's Rule to empower patients and families.
Priorities for improvement in 2025/26 include timely access to pain relief and critical medications, nutrition and hydration, Mental Capacity Assessments (MCA), and the identification and management of deteriorating patients. Specific targets and metrics for improvement in the identification and management of deteriorating patients are:
- Improve the percentage of observations completed at least once an hour.
- Improve the percentage of nurse in charge involvement in NEWS2 5+ patients.
- Maintain percentage of CCOT response time to NEWS2 7+ patients (within 30 minutes)
- Increase percentage of Sepsis Alerts completed.
- Maintain percentage of septic patients being administered antibiotics within 1 hour (>90%)
To improve timely access to critical medications, the Croydon Health Services NHS Trust plans to provide a searchable list to aid identification of critical medication and disseminate an action card detailing the process for nurses to undertake when medication is not available. To improve timely access to pain relief, the trust plans to focus on how they collect data to track improvements. The key performance indicators (KPIs) that will be used to measure the success of these Quality Priorities for Improvement in 2025/26 are:
- Improving Timely access to pain relief: A demonstrable and sustained improvement in compliance with the access to pain relief NICE guidance; by administering pain relief within 30 minutes in adults & 20 minutes in Children. In sickle cell patients the improvement measure will be a 50% improvement in pain score documentation by 6 months and 100% by 12 months.
- Improving timely access to critical medications: To reduce inappropriate omission of critical medicines from 3.5% to below 3% trust wide by the end of 2024/2025
- Improving Nutrition & Hydration: 100% compliance with patient food /nutrition records and 95% compliance with MUST assessment completion within 24 hours of admission
- Improving Mental Capacity Assessments (MCA): 90% of patients with demonstrable evidence of needing an MCA to have it completed. The baseline is 13%
- Improving identification & management of deteriorating patients: Improve the percentage of observations completed at least once an hour. Improve the percentage of nurse in charge involvement in NEWS2 5+ patients. Maintain percentage of CCOT response time to NEWS2 7+ patients (within 30 minutes) Increase percentage of Sepsis Alerts completed. Maintain percentage of septic patients being administered antibiotics within 1 hour (>90%)
The report also detailed the Trust's activity in 2024/2025.
| Activity for 2024/25 | Q 1 | Q2 | Q3 | Q 4 | TOTAL |
|---|---|---|---|---|---|
| Outpatient Appointments | 150,361 | 152,957 | 153,190 | 151,032 | 607,540 |
| Inpatients | 795 | 733 | 837 | 809 | 3,174 |
| Day cases | 7,064 | 7,788 | 8,264 | 8,358 | 31,474 |
| Maternity - Deliveries | 816 | 794 | 792 | 784 | 3,186 |
| Maternity - Babies Born (includes multiple births) | 823 | 804 | 803 | 798 | 3,228 |
| Maternity - Home Births | 8 | 3 | 10 | 21 | |
| Emergency Attendances - Main ED & UTC | 39,991 | 37,803 | 39,602 | 38,183 | 155,579 |
| Emergency Attendances - GP hubs | 15,380 | 14,184 | 15,621 | 14,920 | 60,105 |
| Emergency Admissions | 5,169 | 5,071 | 5,052 | 4,618 | 19,910 |
| Ambulance Arrivals | 8,262 | 8,260 | 8,843 | 9,193 | 34,558 |
| Occupied Bed days (General & Acute) | 42,573 | 41,746 | 42,169 | 42,836 | 169,324 |
| Beds Open | 43,274 | 42,737 | 43,024 | 43,702 | 172,737 |
| Bed Occupancy | 98.3% | 97.6% | 98.0% | 98.0% | 98.0% |
The Public reports pack also included updates on the Adult Social Care and Health Directorate's financial position and the Adults Living Independently transformation programme.
The Well-Led review by Deloitte reflected strengths in the Trust's Board leadership and governance arrangements, with recommendations made to develop and strengthen these further. The details on the methodology and outcome of the review were published as part of the papers for the January 2025 Board meeting in public and can be found online.
The Trust has a range of mechanisms in place to manage risks in respect of quality of care. Our Quality strategy is delivered through various work streams including the Quality transformation program (Achieving Excellence together
). This program has three pillars focused on
- Improving fundamental standards of care
- Strengthening Quality Governance and oversight
- Strengthening Clinical Quality Improvement
The Quality Committee (a sub-committee of the Board) meets every month and is chaired by a Non-Executive Director who is a clinician. The Committee is responsible for monitoring performance against the agreed annual quality objectives and is supported by the monthly Integrated Quality Assurance Group, as well as local Directorate level Quality Governance meetings.
The Trust continues to promote and encourage data protection incident reporting to support and build secure systems and processes. The Trust self-reports breaches categorised as potentially capable of causing harm (level 2 incidents) via the Data Security and Protection toolkit reporting facility. The Trust continues to monitor, improve, and implement advice and lessons learned from reported breaches and incidents.
The Trust plans to address health inequalities through several initiatives:
- Taking part in a national pilot to encourage a more rapid and appropriate response to sickle cell patients in crisis, called 'ACT NOW'.
- Integrated Neighbourhood Teams (INTs) bring multiagency professionals together to improve services for local communities.
- Healthy Communities Together is an innovative partnership between the NHS, the council and the voluntary sector in Croydon aiming to improve wellbeing and reduce inequality by engaging local people to shape services.
- Working with partners in the Asian Resource Centre and Croydon BME Forum, our Expert Patient Forum helps to identify and support residents with high blood pressure, diabetes, and chronic obstructive pulmonary disease.
- Family Hubs are a new way of bringing together all the support a family may need from pregnancy through to young people turning 19 years or 25 if they have a disability.
Specific digital services being developed include:
- Digitization of ECGs: Ensuring they are linked into the patient's record.
- Fetalink: A system allowing staff to see CTG and other information for all mothers in one central place, supporting the provision of remote care and monitoring.
- Upgraded training system: To ensure staff are using the most up to date functionality of the EPR.
- Hardware refresh: Upgrading computers and mobile computers, and replacing WIFI equipment.
These developments aim to improve patient care through better access to information, enhanced monitoring capabilities, and improved staff training and efficiency.
