The Care Quality Commission
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Medway NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings

All Inspections

Various dates between 28 April and 1 June 2021

During a routine inspection

We carried out an unannounced inspection of the trust’s medical care service and an unannounced focused inspection of its children and young people’s service.

At our last comprehensive inspection of the trust, the trust was rated requires improvement overall. Our most recent previous core service inspection was an inspection of the trust’s urgent and emergency care service in December 2020. We rated this specific service inadequate overall. It was the findings from this inspection along with other intelligence, including from trust and stakeholder engagement that led to this inspection at this time, as we had concerns about the quality of services.

During the core service inspections we spoke with 54 staff members including nurses, doctors, managers, allied healthcare professionals, housekeeping and support staff. We held junior doctor focus groups attended by 17 junior doctors and reviewed 31 sets of patient records.

We also inspected the well-led key question for the trust overall. We decided to carry out a well-led assessment at this time, as we had concerns as to the capability and capacity of the trust’s leadership team. The trust had been subject to significant intervention from NHS England and NHS Improvement across several areas of trust service delivery, including support for the trust’s executive being provided by their Intensive Support Team.

As part of our assessment of well-led NHS England and NHS Improvement carried-out a well-led assessment of the trust’s financial governance, which is included in our well-led summary.

Generally the ratings for both the core service inspections and the well led assessment improved.

  • We rated the key questions of safe and well led for its children and young people service as good. We rated its medical care service as requires improvement overall.
  • We rated well-led as requires improvement.

For the medical care core service inspection we found:

  • Medicines brought in by patients were not always recorded at admission and there had been several incidents were medicines had gone missing across a number of wards.
  • The service did not always have enough staff to keep patients safe from avoidable harm and to provide the right care and treatment. However, managers regularly reviewed and adjusted staffing levels and skill mix to meet the needs of the patients including using locum and bank staff to help keep patients safe. The service was actively recruiting nursing and medical staff from overseas.
  • There were clear lines of accountability from the department to the board through the directorate governance structure, but these were not always effective. There was a lack of oversight of issues identified as a risk to patient and staff safety which had not been identified or addressed by the leadership team until we raised them during our inspection. For example, on the temporary coronary care unit, there was a lack of infection prevention and control compliance and the environment was inappropriate creating many risks.
  • Patients were not always put on the correct patient pathway which delayed the start of their treatment and increased the risk of deterioration.
  • Paper records were still in use and not always fully completed or filled contemporaneously in line with trust policy.
  • The service had a back log of serious incidents that were overdue for investigation.
  • The service did not always meet their target for responding to complaints.

However:

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. We observed positive interactions between staff and patients. Staff introduced themselves to patients before providing care and included patients in discussions about their care. This was an improvement from the last inspection.
  • Staff kept detailed records of patients’ care and treatment, although there were separate systems for this. The service primarily used an electronic patient record system but we noted some patient care was recorded on a paper system.
  • The service treated patient concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint.
  • Staff assessed and monitored patients and gave pain relief in a timely way. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.
  • The service had a vision for what it wanted to achieve and each care group had developed individual strategies to achieve this. Staff were aware of the vision and strategy and the part they played in achieving this.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Staff followed guidance in relation to social distancing and the use of personal protective equipment on the wards we visited. However, we escalated our concerns to trust leaders about the coronary care unit as it was unclear if social distancing guidelines were being met due to the environment.
  • Staff felt respected, supported and valued by their colleagues. They told us of strong working relationships that had been formed during the COVID-19 pandemic. However, we received mixed views on the support they received from local and executive leaders.

For the children and young people core service inspection we found:

  • The service had enough staff to care for children and young people and keep them safe. Staff had training in key skills, understood how to protect children and young people from abuse, and managed safety well.
  • The service controlled infection risk well.
  • Staff assessed risks to children and young people, acted on them and kept good care records.
  • The service managed medicines well.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills.
  • Staff understood the service’s vision and values, and how to apply them in their work.
  • Staff felt respected, supported and valued.
  • The service was focused on the needs of children and young people receiving care.
  • Staff were clear about their roles and accountabilities.
  • The service engaged well with children, young people and the community to plan and manage services and all staff were committed to improving services continually.

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

03 Dec to 29 Jan 2020

During a routine inspection

Our rating of the trust stayed the same. We rated it 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 was rated as requires improvement for emergency and urgent care services, surgery and services for children and young people, inadequate for medical care, good for end of life care and outstanding for critical care.
  • We did not inspect maternity, gynaecology, outpatients or diagnostic imaging.

We are monitoring the progress of improvements to these services and will re-inspect them as required.

10 April 2018

During a routine inspection

The trust has implemented a number of changes since our last inspection to improve safety and it was noted, this had been sustained. However, there were still improvements to made in key areas such as retention of staff, mandatory training and ensuring safety checks were completed. There was recognition from the executive and senior management team that there was still work to be done to make sure a culture of safety existed across the whole of the organisation.

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

  • The trust was rated good for effective and caring. We rated safe, responsive and well-led as requires improvement.
  • We did not inspect maternity, gynaecology, end of life care or services for children and young people.

We are monitoring the progress of improvements to these services and will re-inspect them as required.

29, 30 November 5,8,10 and 17 December 2016.

During an inspection looking at part of the service

Medway Maritime Hospital is located in Gillingham, Kent. The trust primarily serves a population of 384,300 people in the Medway and Swale area. The health of people in Medway Unitary Authority is mixed with 13 national indicators of health scoring better and six worse than the England average. Deprivation is similar to the England average and about 11,085 children (21%) live in poverty. Life expectancy for both men and women is lower than the England average.

The trust has a total of 655 beds spread across various core services of which 19 are surgical day case beds. The complement of in-patient beds comprises 300medical beds 164 surgical beds66 children’s beds), 69 maternity beds and 25 critical care bed.

We inspected Medway NHS Foundation Trust on 29, 30 November 5,8,10 and 17 December 2016.

In 2011 and 2012 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). 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 had formalised a buddying agreement with Guys' and St Thomas' NHS Trust. The trust was also subject to additional scrutiny and support from the local clinical commissioning groups 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 NHS Foundation Trust as 'Requires Improvement' overall. Caring and effective and well led were rated as good whilst safe and responsive were rated as requires improvement. 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 to ensure patients received consistently safe care.

Our key findings were as follows:

SAFE

  • Incident reporting culture had been improved.
  • Improvement in the assessment and documentation of patient risk had been delivered by a planned programme of training and enhanced risk assessment tools.
  • The trust had ceased to care for patients within the emergency department corridor as a result of transformed ways of working within the emergency department.
  • Major improvements had been achieved in the management of the estate and fire safety.
  • Although staffing levels had significantly improved there were still areas operating below guidelines, notably in maternity and emergency care.
  • The trust was not always meeting National Specifications for Cleanliness.
  • Safeguarding and mandatory training targets were not being met consistently across the trust for all staff groups.

EFFECTIVE

  • Local audit was now taking place across all services.
  • The trust had significantly improved its mortality rate and is no longer an outlier for the hospital standardised mortality rate (HSMR).
  • Staff understanding of mental capacity was much improved.
  • Appraisal rates across the trust had improved.

CARING

  • Maternity and gynaecology were rated as outstanding.
  • Our observations during the inspection supported the data and the positive feedback received from patients and carers.
  • Handover meetings on surgical wards were managed in a format that compromised patient dignity and privacy.

RESPONSIVE

  • Support to vulnerable patients such as those living with dementia and those with learning disabilities had been significantly improved.
  • Service planning had led to the introduction of new pathways and services aimed at delivering enhanced care for patients.
  • The trust still had a high number of patients who experienced mixed sex accommodation or were in beds not appropriate for their medical specialty.
  • There was evidence of short notice surgical cancellations and delays in discharge from critical care.
  • The trust was not meeting guidance for achieving and reporting referral to treatment times.
  • Processes for the management of complaints had only recently been addressed to ensure the attainment of response targets.

WELL LED

  • The executive team was well established and performing as a highly cohesive unit with a shared vision and clarity of purpose.
  • The national staff survey and our interviews with staff indicated a significantly improved organisational culture.
  • Governance arrangements had been strengthened and there was a clear line of accountability.
  • The strategic and recovery plans were well constructed and supported by appropriate programme management. Furthermore, these plans had been clearly translated into local divisional and service plans.
  • There was a requirement to further develop service level leadership to ensure full engagement of the workforce.
  • Strategies for the management of equality and diversity were under developed.
  • There were services where staff felt exhausted and not involved in service level decision making.

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.

However, there are a number of areas where poor practice was identified that require attention:

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.

  • 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.

There is no doubt that substantial improvements have been made since our last inspection. The leadership team is now fully established and there is a strong sense of forward momentum and control. In addition it is clear that strong leadership and clear communication are leading to an engaged workforce whose morale is now much higher.

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

25-27 August 2015 , 8-9 & 13 September 2015

During an inspection looking at part of the service

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 was the focus of this inspection 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.

The trust reports that the healthcare needs of the local population are greater than most other parts of Kent.  Medway Local Authority was ranked 136th of 326 local authorities in the English Indices of Deprivation 2010 (1st is the 'most deprived').  The Public Health profile for the local population indicates that Medway is significantly worse than the England average for 13 of 32 indicators (41% of indicators) including smoking prevalence, percentage of physically active adults and recorded diabetes. Male and female life expectancy is also significantly worse than the England average.

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 that 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 have since removed this from the trusts registration.  

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

Overall, Medway NHS Foundation Trust has been rated as inadequate. We have rated it good for being caring but improvements were required in providing effective care. The safety, responsiveness to patients' needs and leadership of the trust remained inadequate despite a prolonged period of the trust being in special measures.  

Three of the eight core services have been rated as inadequate; emergency department; medicine and surgery. Three services required improvement; critical care; end of life care and outpatients. Maternity and gynaecology and services for children and young people were rated as good.

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.

  • Safety was not a sufficient priority across the trust; whilst there had been improvements in some clinical areas with regards to the reporting of incidents, there were concerns that not all staff reported incidents. Further, the process for learning from, and embedding changes to practice as a result of incidents was poorly established. A high level of "Silo working" was noted across the hospital which further impacted on the ability of the organisation to move forward with regards to learning from incidents. There was little evidence of robust trust-wide learning and whilst the trust had undertaken initiatives to tackle key areas of clinical concern including the management of sepsis, these initiatives delivered little in the way of improved patient safety. 

  • Facilities across the organisation was observed to be in a poor state of repair; the trust acknowledged that the estate required significant remedial works to ensure the property was fit for purpose.

  • Whilst the clinical areas we visited were visibly clean in the main, compliance against national cleaning standards was found to be poor.

  • Staffing levels across the hospital 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.

  • Performance against national audits was varied. Clinical audits are designed to drive improvements in the delivery of care to patients; we found that whilst there had been improvements year-on-year in some clinical audits, a number of specialities were failing to sustain improvements, outcomes in some audits being reported as being worse than preceding years performance.

  • The trust continued to remain as an outlier for mortality against a range of composite indicators including but not limited to: respiratory conditions, infectious diseases (sepsis), gastrological and hepatological conditions.

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. There was little consideration given to setting ceilings of care.

  • 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 at the time of our inspection. The Trust had plans for over 500 staff to attended focus groups and workshops in January 2016 when they planned to launch the new Vision and Values across the Trust.

  • 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 including members of the executive team.

  • The capability of the board to drive the level of improvement required at Medway NHS Foundation Trust was questionable. Key posts including the Chief Nurse and Medical Director were both filled by interim appointments. Concerns were raised over the abilities and skill set of non-executive directors; the ability of the non-executive team to robustly hold the executive team to account, especially in relation to quality and safety concerns, and more specifically the long-standing poor performance against mortality outcomes was further impeded by the provision of data which was poorly understood and which had been historically unreliable.

  • Whilst the executive was assured that progress had been made against the 18 month recovery plan, the inspection team was not so assured. Reported actions had been listed as "Complete" however we judged that specific actions and changes to practice had not been sustained. Further, there was mixed assurance received from the board with regards to the ability of the 18 month recovery plan to deliver the expected outcomes. The plan was described as "Aspirational" by more than one member of the board; there was limited evidence to reflect whether the current format of the 18 month plan had been challenged, especially in light of the reservations voiced by both board members and front-line staff.

  • 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 NHS Foundation Trust 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.

  • There was a significant delay or lack of response in acting upon recommendations made from external reports which were specifically related to mortality reviews.

  • 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.

  • The neonatal intensive care unit was found to continuing to be providing components of outstanding care pre-term and term neonates.

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

Importantly, 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 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 across the hospital are sufficient to meet the needs of patients.
  • Ensure that patient records are accurate to ensure a full chronology of the care patients have received has been recorded.
  • 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 that 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; the frames were observed to be cracking under the weight. Although entered on the risk register there were no plans in place to address this potential breach of radiation protection regulations.
  • 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.
  • 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 planning 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 and ensure that the structure of meetings is consistent across the organisation.
  • 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.
  • Review its current handover practice. This should include a focus on the structure, quality, and format of the actual handovers. The trust 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.
  • Review the quality of the senior leadership to ensure efficient, supportive and quality leadership.
  • Review its current strategy to improve engagement, morale, recruitment and retention. It must also ensure that it reviews the bullying reported to ensure staff welfare.
  • 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.
  • Produce a critical medicines list to comply with NPSA/2010/RRR009. Improve mandatory training compliance rates.
  • Ensure staff follow trust policy for the administration of anticipatory medication for EoLC patients.
  • 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.

In addition 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.
  • Tracheostomy equipment trolley 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

23-25 April and 1 May 2014

During a routine inspection

Medway NHS Foundation Trust provides acute services to a population of 400,000 across Medway and Swale. It became a foundation trust in April 2008 and employs around 3,880 staff, supported by 700 volunteers. The trust has two registered locations registered with the Care Quality Commission including Medway Maritime Hospital, which is the main acute hospital site and Woodlands Special Needs Nursery, which did not form part of the inspection.

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 Foetal 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 trust is inadequate. We rated it good for being caring, but improvement was required in providing effective care. The safety, responsiveness to patients’ needs and leadership of the trust was rated inadequate.

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 a 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 some areas of good and 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.

 Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.