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Medway Maritime Hospital Requires improvement

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Inspection report

Date of Inspection: 31 December 2013
Date of Publication: 26 February 2014
Inspection Report published 26 February 2014 PDF | 106.08 KB


Inspection carried out on 31 December 2013

During an inspection in response to concerns

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.