Reports from patient environment action teams may be misleading the public into believing hospitals are dirty when in fact they are just old or have poor signposting, the NHS Confederation has warned.

Some older hospitals, in particular, are being rated red, not because they are dirty, but because their buildings are inappropriately designed. PEATs are looking at a range of features, including how good signposting is, whether food is acceptable, the general state of the furniture and car-parking provision, as well as general cleanliness.

Managers at the Royal Albert Edward in Wigan are furious that their hospital originally got a red rating partly because of the distance from accident and emergency to the public toilets.

Andrew Foster, a trust non-executive director and a policy director with the NHS Confederation, said: 'The hospital was built in 1875. It is a bit difficult to reorganise the architecture at this stage.

My trust had not got a single failure on cleanliness. It was all over other issues. '

HSJ, with the help of local community health councils, has uncovered some of the best - and worst - hospitals according to PEAT reports.

Stoke Mandeville's cleaning was approved by the PEAT team, but it fell down on its poor signposting and lack of linen.

Royal Liverpool Hospital was heavily criticised. Internal decoration was shabby; toilets in A&E had blood stains and graffiti, were not working and had no paper or towels, and wards were cluttered with smelly waste containers. PEAT said presentation of food was poor, some meals were undercooked, and the majority were cool to cold and 'thrown' at patients by staff.

Liz Powell, chief officer at Liverpool Central and Southern CHC, said it had been complaining about it for years.

'It has got so bad that only very serious money will improve matters. They have spent the£150,000 allocated - mainly on flooring - and also paid a sum to the contractors, Sodexho, to ensure that cleaning and catering staff are paid a minimum of£4 per hour. '

A trust spokesperson said there were plans for a massive redecoration programme of eight wards and the CAT scanner area. The public toilets were being 'spruced up' and inspections introduced.

Broomfield Hospital in Chelmsford had its second PEAT visit just after Christmas. 'I know the inspection team were disappointed. Small things hadn't been done, like having a notice in the toilets showing they had been checked every hour, ' said Norma O'Hara, chief officer for Mid Essex CHC.

Whipps Cross Hospital in north London got a 'poor' rating. 'A lot of the things they recommend are cosmetic, like improving the front entrance, ' said Francis Hollwey from the local CHC. 'It seems to be more about image rather than the underlying problems of basic cleaning in hospitals. '

City Hospital in Birmingham has managed to stay one step ahead of the game. It managed to get a rates rebate of£854,000, most of which it has invested in improving the hospital environment. It got a poor rating for its toilets after the PEAT visit and has since spent£16,000 upgrading them. Signposting has also been improved and£60,000 spent on new linen.

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