All inspections: Medway Maritime Hospital

Pages 1 and 3 of this report relate to the hospital and the ratings of that location, from page 4 the ratings and information relate to maternity services.

We inspected the maternity service at Medway Maritime Hospital, managed by Medway NHS Foundation Trust, as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

Our rating of this hospital is requires improvement overall.

Our rating of the Maternity service is good. We rated safe as good and well-led as good for maternity.

How we carried out the inspection

We visited the hospital and spent time in all of the maternity areas. There was a Maternity Care unit (MCU), fetal medicine and antenatal clinic area. We also went to The Birth Place, which was the midwifery-led unit. Whilst visiting the delivery suite, we also visited obstetric triage, obstetric theatres and Maternity Enhanced Care Unit (MECU) which was a four-bedded bay offering support to women and birthing people who may need additional care. We visited Pearl Ward which was a ward for antenatal care and contained eight transitional care beds. Induction of labour were also managed from Pearl Ward. Kent Ward was for postnatal care and elective caesarean sections were managed from here.

Following our arrival at the hospital, we observed the morning handovers between midwives and medical handovers.

We spoke with 8 pregnant women or mothers whilst we were on site. We also ran a poster campaign during our inspection to encourage pregnant women, birthing people and those who had given birth who had used the service to give us feedback regarding care. We analysed the results to identify themes and trends.

We also spoke with 26 members of staff, including service leaders, all grades of midwives, including some specialist midwives, obstetric staff, the director of midwifery, the head of midwifery, the general manager, the non-executive director safety board champion and the chair for the maternity voices partnership.

We reviewed performance information about this service before and after our inspection. We reviewed 7 sets of maternity records plus eight prescription charts. We also looked at a wide range of documents including standard operating procedures, meeting minutes, risk assessments, incidents and audit results.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/whatwe-do/how-we-do-our-job/what-we-do-inspection.

A summary of CQC findings on urgent and emergency care services in Kent and Medway.

Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. We have summarised our findings for Kent and Medway below:

Kent and Medway

The health and care system in this area is made up of many health and social care providers and is supported by stakeholders, commissioners and the local authority. We found front line staff working across all services were doing their best in very challenging circumstances and had continued to do so throughout the COVID-19 pandemic.

Increased system wide collaboration, particularly between health and social care was needed to alleviate the pressure and risks to patient safety identified in some services we inspected. However, we did find some good collaborative working; for example, staff in acute and ambulance services had been working together to reduce handover delays, and primary and community services worked together to reduce attendances in Emergency Departments.

We found some access issues in primary care and some GP practices were not allowing patients to enter the building without staff permission; since our inspections, action has been taken to ensure patients can access their GP Practice freely. We did find examples of innovative practice including employing a variety of different healthcare professionals in GP Practices and across Primary Care Networks to better meet the needs of their patients ensuring people receive the right care at the right time. There was also funding available to provide interpreting and translation services to support people from diverse communities and to support people arriving in the UK from Ukraine.

Primary Care Networks were working well with community services to alleviate the pressure on ambulance and acute services where possible, particularly in out of hours services. In addition, technology was being utilised to improve services and provide timely access to patient information, especially for staff providing out of hours care.

Staffing issues and high levels of absence due to COVID-19 had impacted on services across Kent and Medway. GP Practices in this area had a larger number of patients per GP and demand had increased; however, in many cases this was well managed. The NHS111 service had experienced staffing issues as well as increased demand; this had resulted in significant delays in call answering times for people trying to seek advice.

Ambulance response times had also been poor across Kent and Medway. Whilst operational staff had done all they could to maintain response times to serious and life-threatening calls, response times to less serious calls were unacceptable, and performance had continued to be poor for a long time. This had widespread impact on people in Kent and Medway, and particularly on people living in care homes. Social care staff had to provide long periods of enhanced care to people waiting for an ambulance response whilst also caring for other residents.

There continued to be long ambulance handover delays at hospitals in Kent and Medway; however acute and ambulance services had worked well together to reduce these delays and improve handover processes.

Emergency departments inspected in Kent and Medway continued to be under significant pressure. However, we found some improvements since previous inspections, including improvements in leadership and the culture within the departments. Staff worked hard to meet current demands and felt positive about the improvements they had seen. Some social care services had raised concerns in relation to the care provided to people with dementia and autism in emergency departments. Where specific concerns were raised, these were being investigated

There were delays in patients receiving care and treatment caused by poor patient flow across urgent and emergency care pathways. There were many urgent and emergency care pathways available within hospitals in Kent and Medway, however staff acknowledged these were not all working well or being fully utilised. Referral pathways between emergency department and urgent treatment centres aimed to meet people's needs and reduce pressure on acute services. However, we identified issues with inappropriate referrals, long waiting times and inconsistent risk assessments putting people at risk of harm. Patients also reported delays in their treatment due to inappropriate referrals. System partners were aware of issues with UEC pathways and had an action plan in place to address them.

We also found delays in patient discharge from hospitals and a shortage of social care capacity to enable people to leave hospital in a safe and timely way. In addition, social care services reported concerns about poor discharge processes. Examples included insufficient information about changes to medicines or people discharged into care homes who required a level of care for which staff were not trained to provide.

Staff working across Kent and Medway require additional support to manage the continued pressure on services. We also identified opportunities to upskill staff, for example, training additional social care staff in areas such as detecting early signs of deterioration in health. Increased collaboration between health and social care services and stakeholders is needed to address issues with patient flow across urgent and emergency care pathways. These pathways also require evaluation to ensure they are as efficient and effective as possible to meet the needs of people in Kent and Medway.

Medway NHS Foundation Trust is a single-site hospital based in Gillingham. Medway Maritime Hospital serves a population of more than 424,000 across Medway and Swale. The trust employs around 4,400 staff and provides a wide range of specialist and general hospital services to almost half a million patients a year. This includes more than 125,000 emergency department attendances, 88,000 admissions, 278,000 outpatient appointments and more than 5,000 babies born last year.

As an NHS foundation trust, the organisation has a Council of Governors and more than 10,000 public members. The hospital is made up of two clinical divisions; unplanned and integrated care and planned care that are supported by corporate functions. Each division has a dedicated leadership team comprising of a divisional director of operations, divisional medical director and a divisional director of nursing. The board of directors, led by chair Jo Palmer, has eleven executive directors including George Findlay, Chief Executive, and eight non-executive directors.

We found:

Staff did not always keep detailed records of patients’ care and treatment when completing records for urgent and emergency care patients. This included the completion of nursing, falls and skin risk assessments.
Care for patients showing signs of deteriorating were not consistently escalated placing patients at risk.
The department did not always control infection risk well increasing the risk of cross infection.
There was poor flow out of the department, patients experienced substantial delays before being admitted or discharged.
The leadership, governance and culture did not always support the delivery of high-quality person-centred care for patients.

However:

The service had suitable equipment which was easy to access and ready for use.
Generally, staff told us they enjoyed working in the department and spoke of positive working relationships within the team.
Patients had access to a psychiatric liaison 24 hours a day. Staff told us although the team were increasingly busy, they were responsive and would see patients within two hours or initial referral.

Medway Maritime Hospital provides acute and specialist services that serves a population of more than 424,000 people across Medway and Swale.

We conducted an inspection of: Emergency and urgent care, medical care, surgery, critical care, end of life care and services for children and young people. During our inspection, we spoke with 185 staff, 37 patients and 15 relatives. Prior to inspection we held focus groups, where staff shared their views of the organisation with us and we reviewed patients comment cards, which informed us of their experiences of their care.

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

We rated the trust as good for caring, requires improvement for safe, effective, responsive and well led as inadequate.
The trust did not have effective systems to control infection risk in line with best practice. We saw that staff did not always clean their hands or use personal protective equipment (such as gloves and aprons), in line with trust policy.
The risks to people were not always assessed and their safety monitored and maintained to support patient safety. We saw in some areas, basic observations were not taken or recorded routinely. Substances hazardous to health were not stored or managed in line with regulations.
Access and flow through the hospital continued to be a problem in the hospital, which negatively affected patients in all of the services we inspected.
Improvements were slow to be made, or in some cases not made, following our last inspection. As such there was little assurance that the leadership team had the capability or capacity to make and sustain any improvements in their organisation.
Not all leaders had the necessary experience, knowledge, capacity or capability to lead effectively. There was no stability in senior the leadership team, with regular turnover of senior leadership roles. Leaders were not always in touch with what was happening on the front line, and they could not identify or understand the risks and issues described by staff.

However,

The trust had implemented recruitment and training initiatives to address the lack of medical and nursing staff which meant staffing levels met national guidelines in most areas.
Generally, the service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix.
Staff generally treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Feedback from patients was very positive. Staff provided emotional support to patients, families and carers to minimise their distress. Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.
There was an improvement in the incident reporting culture of the organisation, although there was a backlog in incidents at the time of inspection. Processes around serious incident management was still improving and learning from incidents was not shared consistently or across the organisation.

Overall, the mandatory target of 85% compliance was being met by the trust; however, some teams were below the target. We did recognize the rates of compliance had improved and were continuing to improve. This included safeguarding vulnerable adults and children, and mental capacity. Patient were not always in the area of their speciality, patients staying overnight in the recovery areas in main theatres and there were mixed-sex accommodation breaches.
Frequency of cleanliness audits were not always undertaken in line with the national specification for cleanliness.
Safety checks such as safety checks, such as fridge temperatures, emergency equipment and fire safety checks were not undertaken consistently within the emergency department.
There was poor flow and capacity through the emergency department. This meant patients waited many hours in the majors waiting area. Patients experienced significant delays whilst awaiting specialist review or to be placed in a bed on a ward.
In the surgery department, we found the environment was not intact, in line with Department of Health’s Health Building Note 00-09. Additionally, there was a lack of a system to ensure actions and learning from patients’ deaths.
Outpatient and surgery services were not meeting national standards for referral to treatment times.
Although staffing levels in the hospital had improved there were still areas operating below guidelines, notably in surgery and critical care.
Consultant staffing levels in the emergency department remained below the Royal College of Emergency Medicine recommendations. However, since our inspection amendments had been made to the consultant’s rota which increased consultant cover to 14.5 hours on weekdays and eight hours at weekends. Additional cover at weekends was provided by long term locums.
The trust had undertaken a number of initiatives to try and recruit consultants

However:

Staff responded appropriately to the deteriorating patient and treated in line with national guidance. There was effective sepsis management, and understood and their responsibilities to raise concerns and report incidents and near misses.
Clinical staff ensured that patient treatment and care was delivered with kindness and compassion. Staff provided emotional support to patients to minimise their distress. We saw examples where staff included patients in decisions about their care and treatment, and treated them with dignity and respect.
Staff used professional guidance and best practices, including risk assessment tools and safety checklists correctly to support safe care.
We saw good examples of multidisciplinary team working, across the hospital and with external agencies. We observed collaborative working and communication from all members of the team.
Staff understood their roles and responsibilities under the Mental Health Act 1983 and Mental Capacity Act 2005
Staff knew the trusts vision and values and they positively demonstrated these in their practice during the inspection.
Implementation of the frailty model had reduced the number of falls in the community and the number of admissions to the service, and directorate involved patients and the public in developing services.

We inspected Medway Maritime Hospital as part of the Medway NHS Foundation Trust inspection on 29, 30 November 5,8,10 and 17 December 2016. Medway NHS Foundation Trust was identified as a mortality outlier for both the hospital standardised mortality ratio (HSMR) and the summary hospital mortality indicator (SHMI) for 2011 and 2012. Consequently, Professor Sir Bruce Keogh (NHS England National Medical Director) carried out a rapid responsive review of the trust in May 2013 and the findings resulted in the trust being placed into special measures in July 2013. The Care Quality Commission (CQC) then undertook two comprehensive inspections of Medway Maritime Hospital in April 2014 and August 2015. The trust was rated inadequate overall at both of these inspections.

In August 2015 the trust was rated inadequate overall because of concerns relating to patient safety, the organisational culture and governance throughout the trust. Since this inspection the CQC has maintained a heightened programme of engagement and monitoring of data and concerns raised directly with us. The trust was also subject to additional scrutiny and support from the local clinical commissioning groups, NHSE and NHSI through a monthly Quality Oversight Committee which monitored the implementation of action plans to address the shortcomings identified.

This inspection was specifically designed to test the requirement for the continued application of special measures at the trust.

We have now rated Medway Maritime Hospital as 'Requires Improvement' overall. This is based on an aggregation of the ratings for the eight core services we inspected. We were able to see evidence of positive changes taking place across the hospital. However, there were still areas that required improvements so patients received consistently safe care.

The hospital had made improvements to flow through the introduction of a new model for treating medical patients. This was implemented in April 2016 and made significant improvements to the way in which patients’ care was managed.

We found effective systems to assess and respond to patient risk, and significant improvement in this area since our last inspection. These included daily checking for signs of deteriorating health, medical emergencies or challenging behaviour. The hospital had introduced “safety huddles” on the wards and improved staff training in recognising and responding to deteriorating patients. We observed staff recognised and responded appropriately to any deterioration in the condition of patients. Early warning scores were now consistently used across the hospital.

The trust had introduced a new frailty pathway to provide appropriate care for the significant number of patients with complex needs. This enabled staff to treat patients quickly to avoid the need for admission to hospital. The trust had improved their discharge planning and the hospitals delayed transfer of care rate was one of the lowest in England. However, in Surgery the service did not always use the facilities and premises appropriately due to a lack of available beds.

There had been improvements made to the management of patients in the Emergency department (ED). At our previous inspection we found that patients were routinely placed in a corridor where the delivery of safe care had been compromised. At this inspection we found that the corridor was no longer used to treat patients. We also found handovers and safety briefings in ED were effective and ensured staff managed risks to people who used the department. The process of triaging patients had also improved.

The trust had introduced several recruitment strategies. However, staff recruitment continued to be problematic with high levels of bank and agency use in some areas. In some departments staffing did not meet with the recognised standards and guidance. For example, in the emergency department medical staffing did not meet the Royal College of Emergency Medicine minimum requirements for consultant cover, the cardiac care unit (CCU) did not have consistent access to a medical team and in the maternity unit where staffing regularly did not meet its target of ratio of staff to patients, as recommended by Birthrate Plus. In the 2016 staff survey, which included a range of clinical and non-clinical staff, 76% of respondents said there were not enough staff to do their job properly.

There was openness and transparency about safety. Staff understood and fulfilled their responsibilities to report incidents and near misses and were supported when they did. There were effective systems in place to report incidents which were monitored and reviewed. Staff across the hospital gave examples of learning from incidents. Staff understood the principles of Duty of Candour regulations and were confident in applying the practical elements of this legislation.

At our previous inspection , we identified a lack of clinical oversight for patients waiting longer than the targets set for cancer and 18 week pathways. We saw a process of clinical oversight had been introduced and was embedded in the process of monitoring patient pathways. This included weekly patient tracking list meetings, and electronic flags on computer systems to alert staff to patients exceeding their target dates.

Although we saw improvement since our last inspection improvement was still required in relation to staff consistently having appraisals and completing mandatory training in line with trust policy.

We found care and treatment across the hospital was mostly planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. Regular monitoring and audit ensured consistency of practice There were formal systems for collecting comparative data regarding patient outcomes. The hospital routinely monitored and collected information about patient outcomes and used this information to improve care. Benchmarking data showed patient outcomes were mostly similar to national averages. Data supplied demonstrated continuous improvement in some areas since the previous year.

Clinical governance systems, meeting structures and directorate risk registers formed part of the quality assurance and risk management system. Senior staff used the systems effectively to identify and mitigate risk.

At our last inspection we found significant failings in the hospitals estates and facilities management. At this inspection we found there had been improvements, although we still found areas that required attention. The directorate had made some significant changes. These included restructuring the directorate, bringing external contracts in-house (e.g. fire safety and training and a local security management specialist), creating and recruiting a new internal facilities audit team to improve auditing systems, revision of the terms of reference for estates and facilities groups, reviewing policies, and the housekeeping operating plan.

At our last inspection we had significant concerns about fire safety. Fire safety had been significantly improved at this inspection. Kent Fire & Rescue had undertaken a peer to peer review of Fire Safety at the trust. A Fire Action Plan had been created and presented to the trust Board in January 2017 which addressed key fire safety issues. Quarterly fire Safety reports will be provided to the trust Board in future.

Although the hospital was visibly clean, we found instances where clinical environments were not meeting the National Specifications of Cleanliness (NSC). This meant there was inconsistency in the auditing of cleaning standards across the very high risk areas and potentially an increase in the risk of hospital acquired infections.

There were specific areas of the hospital where staff were not feeling the positive impact of changes and where morale was low. This was more evident in theatre staff who were often working beyond the end of their shifts and band five nurses, who were feeling the impact of staff shortages and were often asked to move wards at short notice to cover shortages elsewhere. However, large numbers off staff joined a range of focus groups held at the hospital from different professional groups and we spoke with individual staff as we went around the hospital. The majority of staff we spoke with reported improvements in the organisational culture and were positive about developments at the trust.

We saw several areas of outstanding practice including:

The neonatal unit improved their breast-feeding at discharge compliance rates from one of the lowest rates in the country to the highest. A critical care consultant, nurse practitioner, GP lay member and physiotherapist led an innovative programme to improve patient rehabilitation during their ICU admission and after discharge. This included a training and awareness session for all area GPs and a business case to recruit a dedicated rehabilitation coordinator. In addition, a critical care consultant had developed app software to be used on digital tablets to help communication and rehabilitation led by nurses. The consultant was due to present this at a critical care nurses rehabilitation group to gather feedback and plan a national launch.
Critical care services had a research portfolio that placed them as the highest recruiter in Kent. Research projects were local, national and international and the service had been recognised as the best performer of the 24 hospitals participating in the national provision of psychological support to people in intensive care (POPPI) study. Research projects for 2016/17 included a study of patients over the age of 80 cared for in intensive care; a review of end of life care practices; a respiratory study and a study on abdominal sepsis.
The 'Stop Oasis Morbidity Project’ (STOMP) project had reduced the number of first time mothers suffering third degree perineum tears. The project had been shortlisted for the Royal College of Midwifery Award 2017, Johnson’s Award for Excellence.
Team Aurelia was a multidisciplinary team. Women who were identified in the antenatal period as requiring an elective caesarean section would be referred to team Aurelia. Women were seen by an anaesthetist prior to surgery and an enhanced recovery process was followed to minimise women’s hospital stays following surgery.
The bereavement suite, Abigail’s Place, provided the “gold standard” in the provision of care for parents and families who experience a still birth. The suite created a realistic home environment for parents to spend time with their child.
The frailty and the ambulatory services, which required multidisciplinary working to ensure the needs of this patient group, were met. The individualised care and pathway given to patients attending with broken hips. The care ensured this group of patients’ needs were met on entering the department until admission to a ward. The development and implementation of the associate practitioner role.

Action the hospital MUST take to improve

Ensure flooring within services for children and young people is intact, in accordance with Department of Health’s Health Building Note 00-09.
Ensure all staff clean their hands at the point of care in accordance with the WHO 'five moments for hand hygiene'.
Review the provision for children in the recovery area of theatres and Sunderland Day Unit to ensure compliance with the Royal College of Surgeons, standards for children’s surgery.
Ensure staff record medicine fridge temperatures daily to ensure medicines remain safe to use.
Ensure compliance with recommendations when isolating patients with healthcare associated infections.
Ensure that all staff have appropriate mandatory training, with particular reference to adult safeguarding level two and children safeguarding levels two where compliance was below the hospital target of 80%. Ensure that all staff receive an annual appraisal.
Ensure that an appropriate policy is in place ensuring that patients transferred to the diagnostic imaging department from the emergency department are accompanied by an appropriate medical professional.
Ensure the intensive care unit meets the minimum staffing requirements of the Intensive Care Society, including in the provision of a supernumerary nurse in charge.
Ensure staffing levels in the CCU maintain a nurse to patient ration of 1:2 at all times.
Ensure that consultant cover in the emergency department meets the minimum requirements of 16 hours per day, as established by the Royal College of Emergency Medicine.
Ensure fire safety is a priority. Although the trust has taken steps to make improvements we found some areas where fire safety and staff understanding needed to be improved.
The trust must ensure people using services should not have to share sleeping accommodation with others of the opposite sex. All staff to be trained and clear of the regulation regarding same sex accommodation.
Ensure clinical areas are maintained in a clean and hygienic state, and the monitoring of cleaning standards falls in line with national guidance.
Take action to ensure emergency equipment (including drugs) are appropriately checked and maintained.

Action the hospital SHOULD take to improve

Ensure the electronic flagging system for safeguarding children in the children’s emergency department is fully embedded into practice.
Review safeguarding paperwork to ensure it can be easily identified in patient’s records.
Ensure there is a system in place to identify Looked after Children (LAC) in the children’s emergency department.
Enhance play specialist provision in line with national guidance.
Ensure children’s names and ages or not visible to the public, in compliance with the trusts ‘Code of conduct for Employees in Respect of Confidentiality’ policy.
Ensure compliance with NICE QS94, and ensure children, young people and their parents or carers are able to make an informed choice when choosing meals, by providing them with details about the nutritional content.
Identify risks for the outpatient risk register.
Begin monitoring the availability of patient records in outpatient clinics.
Ensure that referral to treatment times improve in line with the national targets.
Monitor the turnaround times for production of clinic letters to GPs following clinic appointments.
Ensure there is sufficient resource in allied health professionals teams to meet the rehabilitation needs of patients.
Ensure medical cover in the CCU is provided to an extent that nurses are fully supported to provided safe levels of care.
Medicines and IV fluids should be stored securely and safely. Intravenous (IV) fluids were stored in a draw on a corridor on pearl ward this was not secure as it did not ensure that IV fluids could not be tampered with. We found ampoules of metoclopramide and ranitidine, drugs commonly used for stomach problems, stored in a box together. This created a risk that patients may have been given the incorrect medicine.
Ensure equipment cleaning is thorough, including the undersides of equipment.
Ensure complaints are responded to in accordance with the trust’s policy for responding to complaints.
Meet the national standards for Referral to treatment times (RTT) for medical care services and continue to reduce the average length of stay of patients.
The driving gas for nebulised therapy should be specified in individual prescriptions as can be harmful to the patient.
Continue to address issues with flow to improve performance against national standards.
Repair/replace the two patient call bells in the majors overflow area.
Install a hearing loop in the emergency department reception area.
Consider how staff are made aware of internal escalation processes.
Take action to ensure patients recover from surgery in appropriate wards where their care needs can be met.
The trust should take action to ensure there is sufficient access to equipment. In particular, sufficient sling hoists for patients on Arethusa and Pembroke Wards and sufficient access to computers for staff throughout the surgical directorate.

It is apparent that the trust is on a journey of improvement and significant progress is being made both clinically and in the trust’s governance.

I would therefore recommend that, from a quality perspective, Medway NHS Foundation Trust, is now taken out of special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Medway NHS Foundation Trust serves a population of approximately 400,000 across Medway and Swale. The trust became a foundation trust in April 2008 and has a workforce establishment of 4,139 staff; at the time of this inspection, there were 3,683 staff employed by the trust. The trust has two locations registered with the Care Quality Commission (CQC): Medway Maritime Hospital which is the main acute hospital site and the Woodlands Special Needs Nursery which did not form part of this inspection.

Medway Maritime Hospital hosts a Macmillan cancer care unit, the West Kent Centre for Urology, the West Kent Vascular Centre, a regional neonatal intensive care unit and a foetal medicine unit, as well as providing a dedicated stroke service the local population.

Medway NHS Foundation Trust was identified as a mortality outlier for both the hospital standardised mortality ratio (HSMR) and the summary hospital mortality indicator (SHMI) for 2011 and 2012. Consequently, Professor Sir Bruce Keogh (NHS England National Medical Director) carried out a rapid responsive review of the trust in May 2013; the findings from the review resulted in the trust being placed into special measures in July 2013.

In response to information of concern received, we undertook unannounced inspections of the maternity service in August 2013 and the emergency department in December 2013; CQC utilised its enforcement powers and issued a range of warning notices which required the trust to make significant improvements within a specified period of time. The CQC undertook a comprehensive inspection of Medway Maritime Hospital in April 2014 because the trust was rated as high risk in the CQC's intelligent monitoring report and because the trust remained under special measures. We rated the trust as inadequate overall; the emergency department had made insufficient progress since we had issued warning notices in December 2013 and was rated as inadequate as was the core surgery service. We found the maternity service had made significant improvements although there was limited evidence to demonstrate sustained improvement. The service was rated as requiring improvement along with medical care, end of life care and outpatients. Critical care and care of children and young people had been rated as good.

We re-inspected the emergency department in July and August 2014. As a result of those inspections we undertook enhanced enforcement action and imposed conditions of the providers registration which required them to undertake an initial assessment of all patients who presented to the emergency department within 15 minutes of their arrival. During this most recent inspection we were satisfied that the trust was meeting this condition and will remove this condition from the trusts registration.

This most recent announced inspection took place between the 25 and 27 August 2015, with follow up unannounced inspections taking place on 8, 9 and 13 September 2015.

Our key findings were as follows:

Safe

Whilst we acknowledge that incident reporting had improved in some areas we remain concerned that not all incidents were being reported. We are also concerned that senior staff responsible for reviewing and investigating incidents did not always have the time to carry out these duties across all departments because of staffing levels.
The environment within ED was not adequate to meet patient demand. There were frequent occasions when the number of patients requiring treatment exceeded the number of cubicles available. This meant that patients spent a long period waiting in corridors. We found that systems in place to monitor these patients were not safe and patients were not adequately monitored. We also found their privacy and dignity was not maintained. The process for admitting patients to wards was very slow and this meant people had to spend very long periods cared for in the ED. This meant that care was delayed in some cases.
Some areas of the trust were unable to show how they had learned from, or made improvements as a result of, complaints, comments and incidents.
Staffing levels throughout the emergency, surgical and medical departments and the medical high dependency unit (MHDU) were insufficient to meet people's needs. This was also identified at the last inspection. The trust remained heavily reliant on the good will of staff to undertake extra shifts and temporary agency and bank staff in the interim to ease the pressures. There was a lack of robust induction procedures and records for these staff.
Children who received treatment and care at the hospital were kept safe; their safety was assured through vigilant monitoring of any deteriorating child and in providing optimum staffing ratios; the effectiveness of services were geared to reducing emergency re-admission rates and the caring was evident throughout the whole service where a team multidisciplinary approach to care prevailed.
Maternity and gynaecology safety performance showed a good track record and steady improvements. There were clearly defined and embedded systems, processes and standard operating procedures to keep women safe and safeguarded from abuse.

Effective

Staff practice did not always comply with the requirements of the Mental Capacity Act, Deprivation of Liberties Safeguards. We also found staff were not always supported in their development through appraisal in some areas of the trust.

Caring

There was a limited approach to obtaining the views of patients. Staff were caring and supportive with patients and those close to them. Staff responded with compassion to patients in pain or emotional distress, and to other fundamental needs. Staff treated patients with dignity and respect and people felt supported and cared for as a result.

Responsive

Patients were unable to access the care they needed because of inadequate management of demand and patient flow through the hospital. The flow of patients through the hospital did not function as intended. Patients were frequently treated in mixed-sex wards.
The trust was consistently not meeting their two week targets for patients suspected with cancer and in addition to this there was an inequality in waiting times between patient groups. The latest referral to treatment time’s data revealed that the trust was below the NHS England target. Increasing numbers of investigations were being sent to external agencies for reporting, but the trust had no robust assurances of its own that the quality of reporting.
The patient service centre was not always able to give patients appointments within the target times set by NHS England and the clinical commissioning groups. At the time of our inspection we were unable to see any clear strategies to develop robust systems and processes to be able to monitor and maintain these targets.
The End of Life Care Policy (2014) provided by the trust was not robust as it was aimed at care of the dying patient only and there were no prerequisites for advance care planning.
Discharge planning was inadequate and there were high levels of delayed transfers of care.
Staff were unaware of complaints at a directorate level which had influenced change.

Well-led

The vision and values of the organisation were not well developed or understood by staff.
Strategic planning and operational management were hindered at all levels by the lack of reliable, easily understood data. Staff satisfaction was mixed, and some staff reported feeling bullied.
The leadership of core services and divisional leads was lacking consistency and in the latter case, substantive appointees to fill the posts. The structure of the organisation had undergone various reviews since our previous comprehensive inspection; there remained uncertainty about the divisional structures of the organisation, which remained at consultation stage during the inspection.
Whilst the appointment of the chief executive was seen as a pivotal moment in ensuring the leadership of Medway Maritime Hospital was sustainable in the long term, there remained key leadership roles which were filled by interim appointments, with little or no forward vision or plan of how these roles would be appointed to by substantive individuals in the future.
Staff morale had been left in a poor state as a result of ineffective engagement, management and constant changes to directorate teams. The results of the most recent staff survey continued to raise concerns about staff welfare, moral and organisational culture at the trust.
The outpatient nursing team demonstrated good clinical leadership, competent staff, forward thinking and planning with regards to capacity issues. They regularly assessed their environment, sought feedback from and worked with patients regularly to improve the patient experience

We saw several areas of outstanding practice including:

The orthotics department demonstrated a patient centred approach. They had been identified by NHS England as a service to benchmark against, because of the waiting times (90% of all patients seen the same day or next day), low cost per patient and clinical evaluation of each product they used.
The maternity team had "Team Aurelia", a multidisciplinary team that provided support for women identified in the antenatal period as requiring an elective caesarean section. The team undertook the pre-operative review prior to admission for elective caesarean section.
Women were seen by an anaesthetist prior to surgery and an enhanced recovery process was followed to minimise women’s hospital stays following surgery. The hospital play areas for children were very well equipped with a commendable outdoor play area that was well used.

However, there were also areas of poor practice where the trust needs to make improvements.

The trust must:

Take immediate action to improve patient flow. This must be achieved without impacting other services provided within the departments and have a risk balanced approach so not to impede on other services delivered.
Review the environment within the emergency department (ED) to meet patient demand effectively.
Take actions to ensure patients are discharged from the critical care unit within four hours of the decision to discharge to improve the access and flow of patients within the critical care services.
Ensure that staffing levels within adult ED meet patient demand.
Ensure that all patient records in ED are accurate to ensure a full chronology of their care has been recorded.
Ensure there is an effective clinical audit plan in place.
Ensure that major incidents arrangements are suitable to ensure patients, staff and the public are adequately protected and that patients were cared for appropriately in the event that a major incident occurred.
Urgently review the two week cancer pathways for each speciality and ensure that there is clinical oversight of those patients waiting in order to mitigate the risks to those patients.
Provide clinical oversight of patients waiting on incomplete pathways to ensure they are seen on a basis of clinical need in accordance with the trust Access Policy.
Review and provide assurance that processes that are in place to ensure that World Health Organisation (WHO) checklists are completed prior to an interventional radiology procedures.
Ensure Trust wide incident reporting processes and investigations are robust, action plans are acted on and systems are in place to ensure that lessons are learned.
Have robust procedures in place to give assurance of the quality of radiology reporting done by external companies.
Address the risks associated with reducing exposure to radiation in the diagnostic imaging departments. This specifically relates to the wooden door frames supporting the protective lead doors that are cracking under the weight. Although entered on the risk register there were no plans in place to address this potential breach radiation protection regulations.
Ensure that the medical staffing levels in MHDU meet the requirements of the intensive care core standards.
Ensure that MHDU complies with the Department of Health best practice guidance: Health Building Note HBN-04.01.and intensive care core standards.
Ensure that governance and risk management systems reflect current risks and the services improve responsiveness to actions required within the risk register.
Ensure clinical areas are maintained in a clean and hygienic state, and that the monitoring of cleaning standards falls in line with national guidance.
Store confidential patient records securely.
Improve the completion of mandatory training rates.
Ensure there are adequate numbers of nurses on duty at all times to meet its own needs assessment and national guidance.
Review mortality and morbidly in those specialities where outcomes are below national averages to determine if there are any contributing practice considerations to address.
Ensure that all staff understand their responsibilities under the Deprivation of Liberties Safeguards (DoLS) and discharge these in line with legal requirements.
Improve the quality of discharge plans to decrease the number of delayed transfer of care.
Improve the timeliness of responses when managing to formal complaints.
Ensure that governance meetings, including mortality meetings are held as scheduled.
Improve the quality and availability of performance and safety information to all departmental managers and the divisional management team.
Ensure patients undergoing cardiac procedures where they required sedation are treated by appropriately competent staff at all times as outlined in national guidance to minimise the risk to patients.
Ensure clinical oversight of activity provided and ensure appropriate audit trails and quality measurement tools are in place.
Review its current handover practice. This should include a focus on the structure, quality, and format of the actual handovers. It should also review the process to ensure that patients dignity, privacy and Confidentiality is not compromised.
Review the capacity of the safeguarding team and ensure more effective communication and working collaboration from the safeguarding team.
Ensure that local policy and protocol around EOLC are reviewed to ensure they are consistent with national and best practice guidance.
Ensure robust leadership at board and non-executive level to provide an EOLC service as per national guidelines.
Take action to ensure that EOLC patients are not moved in their final hours.
A review of the competency levels of staff responsible for making these decisions should be undertaken and relevant training provided when deficiencies are noted.
A review of the out of hours discharges and frequent bed moves may be useful to identify trends and themes.
Improve the governance, risk and quality management processes in the surgical department.
Review the quality of the senior leadership to ensure efficient, supportive and quality leadership.
Review its current strategy to improve engagement, moral, recruitment and retention. It must also ensure that it reviews the bullying reported to ensure staff welfare.
Approved temperature monitoring devices in ICU and HDUs should be used to demonstrate compliance with recommended temperature ranges and to ensure the quality and integrity of medicinal products is not compromised during storage.
Ensure theatre lists are staffed by appropriately competent staff at all times as outlined in national guidance to minimise the risk to patients.
Store medicines according to the manufacturer’s instructions. Ensure that inappropriate medicines are not stored in ward areas. Ensure it complies with FP10 tracking as dictated by national guidance.
Ensure that IV morphine is not being administered in inappropriate opiate clinical areas by staff that may not be competent to deal with the side effects.
Produce a critical medicines list to comply with NPSA/2010/RRR009. Improve mandatory training compliance rates.
Ensure fridges and Medication storage temperatures are recorded in line with national guidance and best practice.
Ensure staff follow trust policy for the administration of anticipatory medication for EoLC patients.
Medicines in adult ED must always be stored in accordance with trust policy.
Manage allegations of bullying and whistleblowing, and performance management in line with agreed policies. The trust must also ensure it is meeting its duty of care toward staff who are under the care of Occupational Health.

The trust should:

Provide a stable and focussed leadership in divisional teams.
Ensure all staff understand the organisations strategic recovery plan and their personal role and responsibilities in delivering the plan.
Engage patients in the planning, design, delivery and monitoring of services.
The trust statement of vision and values should be translated into a credible strategy with well-defined objectives that are understood and acted upon by staff working in critical care services.
Review the results of the annual infection control audit undertaken in all outpatient and diagnostic imaging areas and produce action plans to monitor the improvements required.
Introduce a policy and protocol to ensure that clinic letters to GPs are dispatched in a timely manner with audits to maintain assurance.
Difficult airway management equipment on SHDU should be checked using a checklist, and a record kept of those checks, to ensure it is readily accessible and fit for purpose.
Ensure all storage areas are fit for purpose and that items are store appropriately. Consider how the fabric of clinical areas is maintained.
Ensure records of 'intentional rounding' are consistently completed. Benchmark its acute medical unit performance against the standards set by the Society of Acute Medicine.
Ensure that 'as required' pain relief is adequately evaluated. Progress the use of specialised pain assessment tools for those with cognitive impairment. Complete and implement the 'Percutaneous Endoscopic Gastroscopy Nutrition Policy'.
Ensure all staff receive an annual appraisal and that there are arrangements for clinical supervision for those who require or request it.
Consider how ward staff could be assured of the clinical competencies of agency staff.
Consider how seven day therapy services could be provided on the stroke unit.
Study the level of service required in ambulatory care to better understand the level of demands and how to meet it.
Audit the dementia friendliness of the design of clinical areas and take appropriate remedial actions.
Consider how 'Better Care Together' and matron visit initiatives could be used to drive improvements. Continue to work towards full provision of seven day services for EOLC.
Children’s services should enhance play specialist provision in line with national guidance.
Assure itself that staff understand the new Duty of Candour regulations.
Assure itself that agency staff are reporting and know how to report an incident.
Conduct a service review of pressure area care and urinary tract infections (UTI’s) to identify any care failings or necessary improvements that are required.
Take action to address the excessive temperatures patients and staff are exposed to on McCullough ward.
Ensure that its medication prescribing policy is being followed.
Review the quality of service provided by the new patient transport provider.
Review the staffing levels in the pain team against the demands of the service to ensure it can meet people’s pain needs and provide an appropriate level of support for ward staff.
Review theatre start and finish times and staffing arrangements for over runs to ensure the department is working to maximum capacity to meet the demands of the service and to minimise the risk to patients from long referral to treatment times (RTT).

Professor Sir Mike Richards

Chief Inspector of Hospitals

On 31 December 2013 we carried out an unannounced inspection of the Emergency Department (ED) at Medway Maritime Hospital in response to information we had received from an anonymous source regarding the safety and effectiveness of the ED. We found that the service was failing to meet the national standards that people should expect to receive. As a result, we issued formal warning notices to Medway NHS Foundation Trust, telling them that they must improve in a number of areas within a specified period of time.

Medway Maritime Hospital was inspected again as part of a comprehensive inspection of Medway NHS Foundation Trust because Medway NHS Foundation Trust was rated as high risk in the CQC's intelligent monitoring system and the trust had been placed into 'special measures' in July 2013 following a Keogh review. This inspection took place between 23 and 25 April 2014 with an unannounced inspection visit on 1 May 2014.

As a result of the comprehensive inspection, overall, the hospital was rated as inadequate. We rated it good for being caring but improvement was required in providing effective care and being well-led. The safety of the hospital and being responsive to patients' needs were rated as inadequate. Whilst some core services were rated as good overall, for example critical care and services for children and young people, the emergency department and surgical services were both rated as inadequate.

We carried out further unannounced inspections of the ED on 27 and 28 July 2014 and again on 26 August 2014. In 28 July 2014 we also reviewed the surgery department to determine whether the trust had commenced making the necessary improvements to the service.

During our inspections of the ED in July and August 2014, we found that the ED lacked robust clinical leadership.

The ED had failed to review and optimally utilise its escalation policy within the ED to avoid the need to 'stack' or 'cohort' patients. Whilst patients were being stacked they were not undergoing regular nursing observations, and were not being seen in a timely manner by medical staff. We therefore took urgent action to impose additional conditions on the trusts legal registration with the Care Quality Commission. These conditions required the trust to operate an effective system which ensured that patients could expect to undergo an initial assessment by a skilled and qualified health care professional within 15 minutes of presentation to the Emergency Department. We also required the trust to report to us on a weekly basis, any patients who were not assessed within 15 minutes to determine whether those patients experienced sub-optimal care or had a poor experience upon initial presentation to the department.

Our reason for imposing these conditions was to ensure that staff working in the ED were acutely aware of all patients present in the department; this helped to enhance the safety of the department; we had previously found that patients who were acutely unwell could experience long delays before being initially assessed.

We carried out a further unannounced inspection of both the ED and the main theatre department on 9 December 2014. The inspection team included a general acute physician and a theatre specialist advisor.

Our key findings of the inspection were:

Emergency Department:

The department continued to experience significant issues with transferring patients to wards once a decision had been made to admit them. Delayed transfer of patients was resulting in patients experiencing delays in being treated once they had presented to the ED. However, the trust had implemented initiatives including undertaking an initial assessment of all patients within 15 minutes of their arrival to the ED. Improvements were required to ensure that patients arriving by ambulance received the same level of care as though who self-presented. This included ensuring that trust policies and procedures were consistently adhered to, including those relating to the management of "cohorted" or "stacked" patients.

Clinical leadership was starting to develop; staff were, however extremely candid with us regarding the current pressures of working within the department.

Theatres:

We found that there had been some improvements in the delivery of theatre services although we were concerned that the department was still not being well-led in some aspects; we have referred our concerns back to the trust executive team. Management of emergency theatres and trauma surgical lists was slowly starting to improve although it was difficult to measure the impact that this was to have on patient experience and the quality of care patients could expect to receive as the interventions remained in their infancy. Patients continued to experience delays in being transferred from the recovery department to a ward bed; this was attributed to the continued and significant capacity issues experienced across the hospital.

Medical Escalation Area - Sapphire Ward

We found that the environment of Sapphire Ward was not conducive to ensure that the individual needs of patients could be met. Capacity issues across the hospital had resulted in excessive numbers of patients being placed on Sapphire ward. A lack of curtains impacted on the privacy and dignity of patients and a lack of piped oxygen and suction potentially placed patients at risk of harm.

On 31 December 2013 we carried out an unannounced inspection of the Emergency Department (ED) at Medway Maritime Hospital in response to information we had received from an anonymous source regarding the safety and effectiveness of the ED. We found that the service was failing to meet the national standards that people should expect to receive. As a result, we issued formal warning notices to Medway NHS Foundation Trust, telling them that they must improve in a number of areas within a specified period of time.

Medway Maritime Hospital was inspected again as part of a comprehensive inspection of Medway NHS Foundation Trust because Medway NHS Foundation Trust was rated as high risk in the CQC's intelligent monitoring system and the trust had been placed into 'special measures' in July 2013 following a Keogh review. This inspection took place between 23 and 25 April 2014 with an unannounced inspection visit on 1 May 2014.

As a result of the comprehensive inspection, overall, the hospital was rated as inadequate. We rated it good for being caring but improvement was required in providing effective care and being well-led. The safety of the hospital and being responsive to patients' needs were rated as inadequate. Whilst some core services were rated as good overall, for example critical care and services for children and young people, the emergency department and surgical services were both rated as inadequate.

We carried out a further unannounced inspection of the ED on 27 and 28 July 2014 to follow up on our findings in April and in response to us receiving information of concern from two separate sources.

Our key findings from our inspection on 27 and 28 July were as follows:

The ED was in a state of crisis with poor clinical leadership. This was despite there being an ED consultant in the department at the time of the inspection and a designated Band 7 nurse in charge. Similar to our previous inspection there was no evidence that nursing, medical and other allied health professionals were working in a joined up manner.

The ED had failed to review and optimally utilise its escalation policy within the ED to avoid the need to 'stack' patients. Whilst patients were being stacked they were not undergoing regular nursing observations, and were not being seen in a timely manner by medical staff.

This was not due to the department being 'overrun' with patients (there were empty cubicles at the time of the inspection) but rather due to poor organisation of staff and lack of appropriate prioritisation of patients.

The ED continued to fail to ensure that children attending the department underwent initial assessment which was in line with national standards.

As a result of the inspection on 27 and 28 July and considering the findings from our comprehensive inspection in April 2014, we asked the trust to provide us with immediate assurances that necessary action would be taken to safeguard patients from the risk of harm.

On 30 July 2014 we formally wrote to the Chief Executive of Medway NHS Foundation Trust setting out our concerns and to request the necessary assurances that appropriate action would be taken to ensure the safety and welfare of patients who used the service. The trust responded, in a timely fashion, to our request for a robust action plan.

We carried out a further inspection of the ED on 26 August 2014; we were accompanied by specialists in the field of emergency and general medicine.

Our findings from our inspection on 26 August were:

The ED continued to lack any form of effective clinical leadership and there remained a lack of cohesive working amongst nursing, medical and allied healthcare professionals.

The process of initially assessing patients in a timely manner remained flawed; in some instances we found that patients were experiencing delays of more than two hours before any effective clinical intervention or treatment was commenced.

We have, and continue to liaise with external stakeholders including Monitor, NHS England and local clinical commissioning groups who have agreed a to work in partnership to support Medway Maritime Hospital. We will continue to monitor the performance of the trust and will report on any regulatory action we may take in the future.

Medway Maritime Hospital provides acute services to a population of 400,000 people across Medway and Swale. The hospital has around 3,880 members of staff, supported by 700 volunteers.

The Medway Maritime Hospital site is home to a Macmillan Cancer Care unit, the West Kent Vascular Centre, an obstetrics theatre suite, a neonatal intensive care unit, a Fetal Medicine Centre, a dedicated stroke unit and the West Kent Centre for Urology.+

We carried out this comprehensive inspection because Medway NHS Foundation Trust was rated as high risk in the CQC’s intelligent monitoring system and the trust had been placed into ‘special measures’ in July 2013 following a Keogh review. The inspection took place between 23 and 25 April 2014 and an unannounced inspection visit took place on 1 May 2014.

Overall, this hospital was rated as inadequate. We rated it good for being caring but improvement was required in providing effective care and being well-led. The safety of the hospital and being responsive to patients’ needs were rated as inadequate.

We rated critical care and services for children and young people as good, but we rated end of life care, outpatients, medical, and maternity as requiring improvement. A&E and surgery were rated inadequate overall.

Our key findings were as follows:

A&E made insufficient progress since the last CQC inspection in December 2013; compared with the maternity department making significant progress since the last inspection in August 2013.
Mandatory training compliance and associated records were insufficient, with significant inconsistencies between local and central records. In addition, there was inconsistent knowledge regarding the availability of training, in particular relating to Deprivation of Liberty training.
Flow throughout the hospital was not efficient, with a particular lack of speciality pull from A&E combined with a lack of proactive discharge.
Data quality throughout the hospital was poor, resulting in the trust board taking assurance from data that was inconsistent and, at times, unreliable.
Governance processes were not robust or standardised, and consequently resulted in difficulty in clarifying whether the themes and trends from aggregated data were reliable.
Junior medical staffing was insufficient and consultants were not providing seven-day service.
Nurse staffing was insufficient and, despite recent significant recruitment, there remained a significant reliance on agency staff, especially out of hours. There was also a significant reliance on medical locum doctors.
While the culture within the hospital demonstrated the majority of the workforce were committed and took pride in their work, there was an evident presence of ‘firefighting’ and lack of objectivity, with a tendency to work locally in their ‘own way’.
The inconsistent leadership within the trust and recent instability in the trust’s future was impacting on the hospital demonstrating collaborative and robust ward to board connection.

We saw several areas of outstanding practice including:

Oliver Fisher Neonatal Intensive care Unit.
Recent provision of the Bernard Dementia Unit.
Improvements made by the maternity team since the last CQC inspection.
WOW awards had been introduced, to enable patients and visitors to tell the trust about a member of staff who had delivered outstanding care.
Use of ‘Schwartz Rounds’ to provide a forum for staff to debrief and explore some ‘challenging’ or emotional experiences that they have encountered when caring for patients.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

Urgently address its poor data quality issues.
Urgently review and standardise risk management and governance both at a local level and trust wide to ensure there are robust processes from board to ward.
Continue to actively monitor its HSMR trends, including ensuring that consistent, robust, minuted mortality and morbidity meetings are being undertaken in all departments.
Ensure that the Vanguard unit is not used as overnight accommodation for patients.
Address its escalation policy within the A&E department to avoid the need to ‘stack’ patients; this should include formal agreement with specialities regarding expected professional standards.
Ensure that the initial assessments of all patients (including children) are in line with national standards.
Address the concerns regarding patient flow through the hospital, including improving discharge processes.
Update its major incident policy in the A&E department and ensure that staff are trained appropriately.
Ensure that there are a sufficient number of nurses with paediatric expertise in the A&E department.
Ensure that all equipment is in date and is checked consistently.
Ensure that all fire exits are accessible at all times.
Ensure that mental capacity assessments (MCA) are undertaken where appropriate and staff are adequately trained in MCA and Deprivation of Liberty.
Commence robust audit theatre utilisation to ensure clear allocation of elective and emergency lists.
Improve the quality of cancellation of operations reporting.
Ensure that all wards have appropriate equipment to meet peoples care needs.
Ensure departments are sufficiently staffed by competent staff with the right skill mix, including out of hours.
Review the current training matrix for mandatory training and improve the recording system so that there is a comprehensive record of compliance with training trust wide.
Ensure all staff are aware of their roles and responsibilities to report incidents and that they have access to Datix. Feedback mechanisms and review processes need to be sufficiently robust to ensure that all staff groups are learning from incidents.
Ensure that Consultant surgeons are undertaking ward rounds at weekends.
Review the medical oversight of the medical high dependency unit and lack of regular input from critical care directorate.
Review the current arrangement for protected consultant presence on the labour ward including the supervision of trainees performing elective caesarean sections.

In addition the trust should:

Review effectiveness of multidisciplinary team working hospital wide.
Continue to work towards full provision of seven day services, including support services.
Improve communication to staff regarding the use of staff car parking so that the improvement of parking availability for patients is fully implemented.
Review outpatient department booking templates to ensure allocated time for clinic appointments are appropriate.
Improve the end of life care out of hours for all patient groups.
Ensure that there is a robust system in place for reviewing risk assessments to ensure they are reflective of the clinical condition of women who are using the maternity service.
Review the Clinical Risk Management Strategy to ensure it accurately reflects the recent changes which have been made to how clinical risk is managed within the maternity department.
Ensure that local policies and protocols are reviewed to ensure they are consistent with national, best practice guidance throughout the hospital.
Ensure that the staff who are responsible for taking blood samples from new born babies undertake revised training in the completion of blood sample labels to reduce the number of incidents whereby blood samples are rejected by the laboratory due to missing or incorrect information.
Ensure that a formalised process is introduced for seeking feedback from patients and/or their parents/carers who use children’s services to help improve the overall quality of the service.
Improve support and communication with staff at all levels.
Review the storage of medicines in theatres and the accident and emergency department.
Review the effectiveness of medical notes library.
Review processes and effectiveness of equipment library.
Review the completeness of records including detaining patients, medicine administration record in accident and emergency department and patients’ weight on admission on surgical wards for high risk patients.
Ensure that all agency staff have completed an induction before they start work and ensure an audit trial of inductions is retained by ward areas.
Review and improve availability of specialist nurses.
Ensure a standard approach to mortality and morbidity activity and encourage independent review and provide appropriate audit trail.

Professor Sir Mike Richards

Chief Inspector of Hospitals

On 31 December 2013 we carried out an unannounced inspection of the Emergency Department (ED) at Medway Maritime Hospital in response to information we had received from an anonymous source regarding the safety and effectiveness of the ED. We found that the service was failing to meet the national standards that people should expect to receive. As a result, we issued formal warning notices to Medway NHS Foundation Trust, telling them that they must improve in a number of areas within a specified period of time.

Medway Maritime Hospital was inspected again as part of a comprehensive inspection of Medway NHS Foundation Trust because Medway NHS Foundation Trust was rated as high risk in the CQC's intelligent monitoring system and the trust had been placed into 'special measures' in July 2013 following a Keogh review. This inspection took place between 23 and 25 April 2014 with an unannounced inspection visit on 1 May 2014.

As a result of the comprehensive inspection, overall, the hospital was rated as inadequate. We rated it good for being caring but improvement was required in providing effective care and being well-led. The safety of the hospital and being responsive to patients' needs were rated as inadequate. Whilst some core services were rated as good overall, for example critical care and services for children and young people, the emergency department and surgical services were both rated as inadequate.

We carried out a further unannounced inspection of the ED on 27 and 28 July 2014 to follow up on our findings in April and in response to us receiving information of concern from two separate sources. On 28 July 2014 we reviewed the surgery department to determine whether the trust had commenced making the necessary improvements to the service.

We were accompanied by specialist advisors in the fields of emergency medicine and surgery on 27 and 28 July respectively.

Our key findings were as follows:

The ED remained in a state of crisis with poor clinical leadership. This was despite there being an ED consultant in the department at the time of the inspection and a designated Band 7 nurse in charge. Similar to our previous inspection there was no evidence that nursing, medical and other allied health professionals were working in a joined up manner.

The ED had failed to review and optimally utilise its escalation policy within the ED to avoid the need to 'stack' patients. Whilst patients were being stacked they were not undergoing regular nursing observations, and were not being seen in a timely manner by medical staff. This was not due to the department being 'overrun' with patients (there were empty cubicles at the time of the inspection) but rather due to poor organisation of staff and lack of appropriate prioritisation of patients.

The ED continued to fail to ensure that children attending the department underwent initial assessment which was in line with national standards.

The Trust had failed to ensure that fire exits remained accessible and free from obstructions at all times. This was specifically related to the Vanguard unit in the ED whereby one exit was blocked with equipment trolleys and also on Victory ward where an exit was blocked with two hoists and an equipment trolley. In both areas these issues were brought to the attention of the nurse in charge at the time of the inspection.

Patients undergoing surgical procedures in the main theatre department continued to experience delays being transferred from the recovery area to ward beds.

Patients waiting for surgery continued to be cancelled for a range of reasons and the process of managing patients requiring non-elective surgery remained informal and un-structured although we were told that initiatives had been proposed to streamline the CEPOD service, commencing in September 2014.

As a result of this inspection, and considering the findings from our comprehensive inspection in April 2014, we have asked the trust to provide us with immediate assurances that necessary action will be taken to safeguard patients from the risk of harm. We have, and continue to liaise with external stakeholders including Monitor, NHS England and local clinical commissioning groups who have agreed a to work in partnership to support Medway Maritime Hospital. We will continue to monitor the performance of the trust and will report on any regulatory action we may take in the future.

The inspection was carried out in response to anonymous concerns raised with CQC during December 2013, and concentrated solely on the hospital's emergency department.

The Board of Directors had been aware since the NHS England review in May 2013 that the emergency department was not fit for purpose in relation to its design and capacity for people attending from the surrounding areas. A representative from the NHS Trust told us that a Clinical Health Planner had been appointed to facilitate the emergency department development, and to work with the emergency department team to agree the changes that were required. The Chief Executive told us that the management had received confirmation during December 2013 that work to improve the design and capacity of the department could go ahead.

We found that some changes had been implemented in response to the NHS England review. This included some additional staffing for day and night shifts, for both doctors and nursing staff. We were informed that recruitment procedures were in place for further increases in staff, but there was difficulty in obtaining staff with the suitable experience and qualifications to work in this department.

The anonymous information sent in to CQC was primarily in relation to the care and welfare of people receiving treatment in the emergency department, and in regards to cleanliness and infection control in the department. The inspection team therefore concentrated on these two outcomes.

The inspection team consisted of four CQC Inspectors, and one specialist advisor in NHS emergency departments. We commenced the inspection at 07.00, so that we could assess the impact of the numbers of people who had attended the department during the previous night. Two inspectors and the specialist advisor concentrated mainly on assessing people's care and welfare during their time in the emergency department. Two other inspectors concentrated mainly on the management of infection control within the department. The inspection visit lasted for over eight hours. We talked with people receiving care, relatives, staff and management during this time.

The department's lack of capacity in respect of facilities and numbers of doctors and nurses on duty was severely impacting on the care and treatment provided to people attending the department, especially those arriving by ambulance. The hospital had insufficient cubicles and trolley bays to provide placements for people being brought in. A mobile unit was in use outside the emergency department and was adjacent to the ambulance bay. This was called the Vanguard unit, and was being used during the day times as an overflow area where patients being brought in by ambulance could be assessed. It was installed as part of the programme of work to improve the design and capacity of the department. Patients should have been in this unit for a maximum of 30 minutes (according to the Trust's policy), before being moved into the main department. This was not happening in practice due to the lack of capacity of the facilities in the main department, and due to insufficient numbers of medical and nursing staff. There was subsequent overcrowding in the unit, as well as in the main department. The unit had also been opened overnight prior to our visit, to try and ease overcrowding in the main department.

Patients on trolleys within the main department were being attended to by a Hospital Ambulance Liaison Officer (HALO). We noted that if these patients had suffered any deterioration in their health they would not have been adjacent to resuscitation and other vital equipment.

On our arrival in the department there were 20 patients who had been in there for more than four hours, waiting to be seen by doctors. Seven of these had been in the unit for over 11 hours, and one patient had been there in excess of 19 hours. Staff and a person's relative reported that during the preceding night there had been up to 17 people on trolleys in the corridors waiting to be seen, and 16 ambulances waiting for spaces to bring in more patients. A staff member said that there had not been a free cubicle for five consecutive days. The Clinical Decision Unit (CDU) was being used as the Acute Medical Unit (which was closed), and was full to capacity. CDU is an area for patients waiting for test results or other medical decisions, and should be a short stay unit. One person had been in this unit for over 22 hours, on a trolley.

We found that patients in CDU were not in single sex areas. A staff member said, 'We try as much as we can to make it single sex, but it doesn't always happen.' People in CDU were very tightly packed together in mixed gender bays with curtains that were hanging from the railings. This compromised people's privacy and dignity.

People said that the nurses and doctors were 'Excellent' when they eventually saw them. However, we found that a number of patients had not received basic care needs while they were waiting. This included a patient who was cold and had asked for a blanket at 04.00, and had still not been given one at 08.00; and a patient who had not been offered any food or drink for 18 hours, although this person had no medical reason to prevent or restrict them from eating or drinking.

We viewed all areas in the department, and saw that it was not visibly clean in all areas. For example, we saw cubicles with visibly dirty radiators and paintwork, stained floors and dirty wash hand basins; and blood spatters on a wall in the Vanguard unit.

The resuscitation area was cluttered with boxes and equipment on the floors including sharps bins. Single use resuscitation equipment was open and not covered or protected from cross contamination. For example, we saw a set of laryngoscopes and their blades lying on a trolley (a laryngoscope is an instrument used for a medical procedure to view the patient's throat, and is used in resuscitation for people who are unconscious). These were out of the packaging and not covered. On the same trolley were oral airways (used to support patients' breathing when unconscious, and to prevent the tongue obstructing the patients' airways) which also were out of their packaging and not covered. This meant that there was a risk of cross contamination of equipment.

The cubicles and trolleys had dates on them showing when they were last cleaned. Many of these were dates which were several days or weeks before the date of our visit. We saw that many curtains between cubicles were visibly stained or dirty. This did not provide confidence for patients coming into the department that all areas were being properly cleaned and managed appropriately.

We found that the emergency department was not compliant with these two outcome areas and was effectively in a crisis situation. More than one member of staff described the situation as 'Under siege', and another said, 'I personally don't think we are being supported; it's a constant battle.' A relative stated 'The staff have been nice; they couldn't work any quicker', and we saw that medical and nursing staff were working very hard to try and treat people appropriately. However, there were too many patients for the capacity of the department, and too few staff to meet their needs.

This inspection was carried out to inspect only the Regulated Activity for Maternity and Midwifery Services provided by the Trust. We made the decision to look at this one area of the Trust after noticing a slight increase in the numbers of notifications of incidents which included ante and post natal women, and neonates.

In each area of the unit we looked to see if the service was safe, effective, caring, well-led, and responsive to people's needs.

The inspection was carried out by a team of five CQC inspectors, one compliance manager, two pharmacist inspectors and four clinical advisors. These included a practice matron with theatres experience; a senior midwife with management experience; a hospital manager; and a consultant obstetrician. We visited the maternity wards, delivery suite, antenatal clinic, and three locations in the community, over the space of four days and one evening.

During the visit we talked with groups of staff including doctors, registrars, consultants, midwives and supervisors of midwives. We also talked with staff on an individual basis. We had conversations with 14 women receiving care, and talked with seven relatives.

We found that women were involved in decisions about the birth and where they wanted this to take place. However, there was no clear pathway for women to know how to register with the service when they found out they were pregnant. This resulted in delays for some women to access antenatal care.

All of the women that we talked with expressed their satisfaction with the standards of care they received and spoke highly of the midwives and other staff who attended to them. However, the management of care was affected by insufficient numbers of midwives, both in the hospital and in the community. This was particularly evident in the provision of post natal care, where midwives struggled to keep up with the demands on them.

We found that medication was administered appropriately, but some of the medication management had elements of poor practice. There was no pharmacy input for the maternity services.

Staff training programmes were available but were not completed satisfactorily by all staff. Midwives in the community were unable to access training easily due to ineffective IT systems. Hospital and community midwives said they did not have time to carry out on-going training programmes and felt unsupported in their job roles. Whereas junior doctors felt supported in their training and found the hospital a good place to work.

We found that systems of governance and management oversight were inadequate. There was poor communication between different directorates. The hospital did not have a service delivery plan for the maternity services, and had not taken into account the changing demographics in the area and how to meet the needs of women in the future. The electronic systems in use were unsupportive and did not serve the needs for the directorates to liaise competently with each other.

People told us what it was like to be a patient in Medway Maritime Hospital. They described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people in hospitals were treated with dignity and respect and whether their nutritional needs were met.

The inspection team was led by a Care Quality Commission (CQC) inspector joined by a second CQC Inspector, a practising professional and an Expert by Experience. Experts by Experience have personal experience of using or caring for someone who uses this type of service. A CQC Evidence and Information Officer joined the lead Inspector on the second day of the inspection for a more detailed analysis of some of the documentation.

During the visit we carried out a 'Short Observational Framework Inspection' (SOFI). SOFI is a specific way of observing people's care to help us to understand the experience of people who are unable to talk with us.

We talked with patients, relatives, visitors and staff during the visit, on three wards and in three departments. This included two wards for older people, and one ward for stroke patients which included older people. We also visited the Emergency Department, the Medical Admissions Unit, and the Discharge Lounge. This enabled us to assess the arrangements for managing privacy, dignity and nutrition throughout the hospital process.

Some of people's comments included the following:

'The staff are wonderful. They can't do enough for us.'

'Sometimes call bells are not answered very quickly.'

'It was very scary coming into hospital at first, but I have been very impressed with how much the staff have all helped me. I have been here for three weeks, and the care has been excellent all the way through.'

'Staff are caring, considerate and respectful.'

'The staff have told me why I am here and what they are going to do to help me go home again.'

'The nurses ought to have gold medals; they are always polite, and always help you.'

Relatives said:

'This ward had improved tremendously since my relative was here a year ago. I must say this is mainly due to the drive and hard work of the ward sister. My relatives and I spend most of the day here in shifts, and I have never seen anything untoward going on here.'

'I have been given good information all the way through about my brother's care. '

'We are very pleased. The staff are good and the care is excellent.'

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 carried out this inspection visit to check how the Emergency Department was functioning at a traditionally busy time of year. We only assessed the Emergency Department at this visit.

The visit took place from 07.30 ' 09.30, and during this time we talked with eight clinical and nursing staff members, and three people waiting to receive treatment.

We gave feedback to senior management staff at the end of the visit.

People who were waiting for treatment said that they liked the 'navigation system', whereby people were seen by a triage nurse as soon after arriving in the department as possible. The three people that we talked with said they had been seen immediately after arriving. The nurse had obtained their contact details and basic symptoms in a private triage area before they booked in at the reception desk.

Two people said they had previously visited the Emergency Department for treatment on other occasions, and had found the staff to be helpful, and had not had to wait for too long.

Staff that we talked with said that although the department had been busy over the Christmas period, there had been sufficient numbers of staff. They had not had any difficulty in obtaining support and advice from on-call medical staff.

We visited three wards and the Accident and Emergency Department to follow-up improvements made since the last inspection visit in February 2011.

We spent a total of eight hours in the hospital over two days, and talked with patients, relatives, and a volunteer; and nursing, clinical and management staff.

We received the following comments from patients:

'I am very pleased with everything. The staff are marvellous."

'I have no complaints. I have been a bit bored, but I have been looked after very well."

'The staff are friendly and caring. I have been given drinks whenever I want one. I have not had to wait a long time to have my bell answered."

'I have been here a week, and it has all been ok.'

One patient said 'I am waiting for a bath, and I want to know when I am going home."

Relatives said:

'X has been kept clean and comfortable. Other family members have spoken very positively about the care given to him.'

'X cannot feed himself, but the staff spend time doing that, or let me help."

'I think that general care is given well. The staff answer the bells, and my relative is always shaved and has clean bed linen.'

One relative said that they had 'a small concern regarding communication, but general care has been good."

Another relative said that there was usually a calm atmosphere, and this gave them confidence in the way the ward was run.

People said that the hospital was kept clean, and had suitable day time facilities for visitors. Visiting times were flexible and staff were helpful.

Patients generally thought that the standards of care were good, and that they were treated with respect and dignity. Most said that they found the clinical staff to be hard-working, kind and supportive. On one ward they said that some staff had 'an attitude' and did not pay them the attention they would have liked, but this was a minority number.

Patients said they were aware of the treatment they were receiving, and were asked to consent to different interventions. Most said that they 'had no complaints' and found the hospital experience to be acceptable.

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.

All Inspections

A summary of CQC findings on urgent and emergency care services in Kent and Medway.

Action the hospital MUST take to improve

Action the hospital SHOULD take to improve

Professor Sir Mike Richards

Our key findings were as follows:

Safe

Effective

Caring

Responsive

Well-led

We saw several areas of outstanding practice including:

The trust must:

The trust should:

Professor Sir Mike Richards