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Medway Maritime Hospital Requires improvement

We are carrying out a review of quality at Medway Maritime Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 26 July 2018

  • 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


  • 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.
Inspection areas


Requires improvement

Updated 26 July 2018



Updated 26 July 2018



Updated 26 July 2018


Requires improvement

Updated 26 July 2018


Requires improvement

Updated 26 July 2018

Checks on specific services

Medical care (including older people’s care)


Updated 26 July 2018

Staff responded well to the deteriorating patient and there was effective sepsis management. They understood their responsibilities to raise concerns and report incidents and near misses.

Compliance to mandatory training met the trust target of 85% and continued to improve, reaching a rate of 87% in June 2018.

The service had sufficient medical and nursing staff to provide safe care and treatment. Staffing levels were reviewed regularly to respond to changes in demand.

Although compliance to mandatory training rates was below the trust target, the rates were continuing to improve.

The service provided care and treatment based on national guidance and evidence of its effectiveness. Patients had comprehensive assessments of their needs, and staff worked collaboratively to understand and meet the range and complexity of patients’ needs.

Staff were competent to do their roles and had opportunities to attend external training course. However, consent was not always obtained or recorded in line with relevant guidance and legislation.

Patients were frequently admitted to areas outside of the speciality they required, and discharges delayed. The service’s referral to treatment times was worse than the England average. However, there were systems in place to aid the delivery of services to patients living with dementia, a system to be able to flag patients with additional or individual needs.

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 found managers promoted a positive culture that supported and valued staff. However, the vacancy rate for the directorate was worse than the trust target and staff did not have a clear understanding of the new management structure.

Services for children & young people


Updated 17 March 2017

At our previous inspection in 2015, we rated the services for children and young people overall as good. On this inspection, we have maintained the overall rating as good, as the overall standard and quality of care has been maintained.

At this inspection overall we rated services for children and young people as good because:

  • Risk was managed and incidents were reported and acted upon with feedback and learning provided to staff.

  • There were effective systems in place to report incidents. Incidents were monitored and reviewed and staff gave examples of learning from incidents. Staff understood the principles of Duty of Candour regulations, were confident in applying the practical elements of the legislation.

  • Treatment and care were effective and delivered in accordance with National Institute of Health and Care Excellence (NICE) guidelines and other best practice guidelines. There was effective multidisciplinary team working within the service and with other agencies. The service also participated in national audits and implemented local audits such as infection control audits.

  • Staffing levels and skill mix were planned, implemented, and reviewed to keep children and young people safe at all times.

  • We found all clinical areas visibly clean and the equipment was fit for purpose and well maintained.

  • We saw that parents were fully informed prior to consent being obtained and that nursing and medical records had been completed appropriately and in line with each individual child’s needs.

  • Staff skills and competence were examined and staff were supported to obtain new skills and share best practice.

  • We observed good team working both within the services for children and young people and externally with other wards and departments that children had contact with.

  • All parents and young people spoke highly of the approach and commitment of the staff that provided a service to their children. We saw good interactions between staff and children, young people and their families. The caring attitude of all staff was obvious in every department we visited. Staff had expertise in caring and communicating with children and young people. Support and equipment was also provided for mothers on the neonatal unit to assist with breast-feeding.

  • There were clear governance arrangements in place that monitored the outcome of audits, complaints, incidents, and lessons learned throughout the service. Staff were positive about the culture in children’s and young people’s services and felt supported by senior managers in the trust.


  • A recommendation from the previous report was there should be an electronic flagging system for safeguarding arrangements in the children’s emergency department. On this inspection, an electronic flagging system had been implemented but was not yet fully embedded into practice.

  • There was no flagging system to identify Looked after Children (LAC) in the children’s emergency department, as staff in children’s emergency department told us they relied on children or their parents/carers to inform them.

  • A recommendation from the previous report was children’s services should enhance play specialist provision in line with national guidance. The play specialist provision had not been enhanced since the previous inspection.

    Safeguarding documentation was on yellow paper along with other documents including consent forms and day care unit documentation for paediatric surgery; this made it difficult to distinguish safeguarding documentation in children and young people’s notes.

  • The service was not complying with National Institute for Health and Care Excellence (NICE) Quality Standard (QS) 94, as children were not given a menu to read, and we told the meal choices. This did not allow children and young people or their parents and carers to make informed choice when choosing meals, as they are not provided with the details about the nutritional content. Children and parents we spoke with told us they had a low opinion of the quality of meals provided.

  • There was no dedicated paediatrics recovery area in theatres. There was no segregation of children from adults in the recovery areas of the theatres. This meant children were directly opposite adult post-operation patients, other than a drawn curtain. In addition, parents were not always able to be with their children in the recovery room due to adult post-operative patients being present. This was not in accordance with The Royal College of Surgeons, standards for children’s surgery.

  • We saw children’s names and ages on a white board, which was visible to the public. This did not comply with the trusts ‘Code of conduct for Employees in Respect of Confidentiality’ policy.

  • Fridge temperatures on medicine fridges were not consistently recorded.

Critical care

Requires improvement

Updated 26 July 2018

  • Patient flow throughout the hospital resulted in delayed discharges and very high occupancy rates. This was having a significant impact on discharges from the medical and surgical high dependency units.
  • Patients were being cared for in recovery beds when no intensive care bed was available. This impacted on nurse staffing and posed an increased risk and unsuitable environment of care for critically ill patients.
  • Out of hours discharges (between 10:00pm and 7:00am) were above national average.
  • Nursing cover did not always meet the minimum requirement in line with the Guidelines for the Provision of Intensive Care services 2015. This included ratio of nurses to patients and the availability of a supernumerary nurse in charge.
  • There was a shortage of medical cover for critical care units. This was identified in the service’s risk register. There were however remedial actions being taken in recruitment and training initiatives.
  • Staff did not feel they understood the senior leadership structure since this had been reorganised in the last two months and staff commented the senior management team was not always accessible or visible.
  • There was a lack of middle management stability and staff had concerns over key people leaving the service. During inspection the matron was present and was leaving after the week of inspection. The internal secondment advert was in place, but when speaking to staff and to the matron during inspection no one had been appointed yet and there was a plan to escalate a member of staff to the role but had not been put into place.
  • Staff feedback was that they related to the vision and values identified but did not feel they had a voice in the decision-making processes. For example, there had been a change of visiting times for patients and unit staff were not consulted on the impact of this.


  • Care was evidence based and staff used national guidance and the service was looking at ways to improve patient care and treatment. The critical care service was actively engaged in research to improve patient care and treatment.
  • The needs and preferences of different people were taken into account when delivering and coordinating services. These included coordinating care with other services as well as families and carers. Patient feedback was consistently positive.
  • Medical staff compliance to mandatory training had improved and was better than the trust target.
  • There was a governance structure to manage the service and the leadership team implemented measure to address risks and performance effectively and regularly reviewed these.
  • There was a strong focus on continuous learning including the use of external accreditation and participation in research.

End of life care

Requires improvement

Updated 17 March 2017

At our previous inspection in 2015, we rated end of life care (EoLC) overall as requires improvement and said the trust had to improve compliance with anticipatory medication, provide EoLC training to hospital staff and full seven-day services.

On this inspection we have rated EoLC as requires improvement, because:

  • While there had been considerable work done to improve the service, we found the governance structure was not well established. It remained unclear that EoLC governance could be fully demonstrated at this stage and we concluded it was too soon to tell if the measures being implemented translated to established systems that effectively monitored and managed clinical quality and performance.

  • Senior managers readily and transparently acknowledged this and stated EoLC was on an improvement 'journey', which was consistent with our own observations and comments made to us by staff and patients.
  • Side rooms and interview rooms were not always available for patients at the end of their lives or their families. Facilities were not available for relatives to stay by the bedside and the hospital did not always provide the appropriate surrounding and privacy relatives required.
  • Patients did not have face-to-face palliative care services seven days a week.
  • It was unclear if actions and discussions from the EoLC steering group were shared widely across teams.
  • Death certificates were not always issued in a timely way.


  • We found that the EoLC team had significantly increased in size and demonstrated a high level of specialist knowledge. There was a newly implemented leadership structure that had resulted in improved policy, procedures and a daily presence on the wards.
  • There were sufficient staff with the right skills and staff had been provided with mandatory and additional training for their roles. Completion rates for mandatory training were better than trust targets.
  • 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.
  • The departments we visited were visibly clean and there were appropriate systems to prevent and control healthcare associated infections. There was sufficient equipment available to meet patients’ needs.
  • Mortuary services had received investment that resulted in increased capacity and improved facilities.
  • In the majority of patients’ medical records, we found ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ (DNACPR) orders prominently presented at the front of the record folder.
  • Medicines were managed safely in accordance with legal requirements and anticipatory prescribing was utilised effectively.
  • EoLC staff were sensitive, caring, and professional. Patients’ complex symptoms were controlled and patients and those close to them were supported.
  • Spiritual and religious support was available through the interfaith spiritual care team. The chapel, recuperation rooms and viewing suite in the mortuary were suitable to meet the needs of service users and their families.

Maternity and gynaecology


Updated 17 March 2017

At our previous inspection in 2015 we rated the service as good. On this inspection we maintained a rating of good as the overall quality of care for patients had been maintained.

At this inspection, overall we rated maternity and gynaecology services as good. This was because:

  • People were being protected from avoidable harm and abuse.

  • Openness and transparency about safety was encouraged. Staff understood their responsibilities in relation to incident reporting. Incidents were investigated appropriately by staff with the necessary clinical knowledge who had received training in leading such investigations. We were given examples of where changes to practice had been made following incidents.

  • Overall, medicines practice met practice guidelines. However, we found two areas where medicines were not stored appropriately.

  • The services, wards and departments were clean and, overall, staff adhered to infection control policies and protocols. However, we found some areas that had not been cleaned appropriately following spillages, and areas which were not cleaned to required standards. We also found that staff were not always washing their hands in line with trust policy.

  • Performance demonstrated a consistent track record and steady improvements in safety. Record keeping was comprehensive and audited on a regular basis.

  • Decision making about the care and treatment of patients was clearly documented. The service used systems of observation to drive improvement in the timely identification of patients at risk of unexpected deterioration. It had allowed for oversight of patients with elevated risk and concerns were escalated for review by the medical teams.

  • Treatment and care was generally provided in accordance with the National Institute of Health and Care Excellence (NICE) and Royal College of Obstetricians and Gynaecologists (RCOG) evidence-based national guidelines. Maternity and gynaecology had an MDT approach in the care of women and babies.

  • There was a range of national and local audits with action plans. In response to audit results action plans were reviewed and monitored providing evidence of good outcomes for children and young people.

  • Leadership was good and staff told us about being supported and enjoyed being part of a team. There was evidence of multi-disciplinary working with staff working together to problem solve and develop child-centred evidence based services which improved outcomes for children and young people.

  • Development opportunities and clinical training was accessible and there was evidence of staff being supported and developed in order to improve services provided to women.

  • Feedback from women and their families was continually positive about the way staff treated people. We saw staff treated women with dignity, respect and kindness during all interactions. Women and families told us they felt safe, supported and cared for by staff.

  • There was an embedded culture of caring, which was demonstrated by the team winning the Johnson’s Excellence in maternity care award at the annual RCM national awards. Staff listened and responded to women's needs as shown by the introduction of the 'Induction of Labour Team' and the 'Patient Satisfaction Following Emergency Caesarean Section' project.


  • The maternity service was not meeting it ratio of staff to patients every month.

  • There were no guidelines in place in regards to babies’ identification.

  • The maternity unit had closed on seven occasions between April 2015 and July 2016 due to the neonatal unit (NNU) being closed. However, the service had followed trust procedures in regards to unit closures.


Requires improvement

Updated 26 July 2018

Our overall rating of this service stayed the same. We rated it as requires improvement because:

  • While the service improved in some areas, it stayed the same or became worse in others since the last inspection.
  • The service could not be assured if nursing staff were appropriately skilled or competent to carry out their roles, to provide safe care.
  • Ineffective paper systems in theatres and shifts for medical staffing created risks to data quality, timeliness of the data collected and the loss of personal and confidential information.
  • The service did not meet Department of Health’s Health Building Note (HBN) 00-09: infection control in the built environment HBN 00-09. The service had not addressed the worn floors in the corridor to the theatre since the last inspection. We also saw a damaged wall in an anaesthetic room. This created the risks of spreading infection as damaged areas can make cleaning difficult.
  • While the service had improved staff recruitment, there remained significant challenges to retain staff. This caused gaps in rota coverage and high reliance on bank and agency staff. This issue was identified at the last inspection and continued to require improvement.
  • Actions and learning from patient deaths had not improved since the last inspection. Information about actions and learning was not always complete and there was not a system to ensure learning was discussed and shared with staff.
  • The trust did not meet the Department of Health’s standard on eliminating mixed sex accommodation.
  • Capacity to manage the number of patients being admitted led to significant shortfalls in the responsiveness of the service. This issue was identified at the previous inspection and continued to require improvement.
  • Staff morale was low and felt the return of a bullying culture after a short-lived positive experience since the trust came out of special measures. Communication from the senior management team was poor.


  • Following this inspection, trust information provided to us showed an overall 85.5% of staff had completed mandatory training as at June 2018 achieving the trust’s training completion target of 85%. This meant staff had the correct level of training in line with trust policy. Having a sufficient level of mandatory training meant staff were supported in fully and correctly applying the appropriate skills for their roles.
  • There were correct processes around the safe management of medicines, including controlled drugs. This had improved since the last inspection.
  • Patients were provided privacy and dignity during intimate examinations and personal care. This was identified as an issue in the last inspection.

Urgent and emergency services

Requires improvement

Updated 26 July 2018

  • The emergency department did not meet the requirements of the Royal College of Emergency Medicine guidelines of consultant cover. The requirements state that consultant cover must be provided a minimum of 16 hours a day. This remained unchanged since our previous inspection when we found consultant cover within the department still did not meet these requirements.
  • Some issues that we identified during the previous inspection had not been effectively addressed. These included, daily safety checks of emergency equipment, daily monitoring of fridge temperatures, an open door in the majors escalation area and a lack of fire safety monitoring. This meant the systems put in place after our last inspection to address these issues were ineffective.
  • Compliance in mandatory training for medical staff was 79%% which did not meet the trust target of 85%. However, compliance in mandatory training had improved since our last inspection and was an improving picture and as at June 2018 was 83.8%.
  • Compliance in Mental Capacity Act training amongst medical staff was 68%, which did not meet the trust target of 85%.However,staff demonstrated a good understanding of the Mental Capacity Act and safeguarding of vulnerable people. Patient consent to treatment was undertaken in line with trust policy and national guidelines.
  • Over the 12 months from February 2017 and January 2018, 22 patients waited more than 12 hours from the decision to admit until being admitted. The highest number of patients waiting over 12 hours was in January 2018 with 15 patients.

  • Patients and visitors were able to access all areas of the adult department, as access was not restricted to staff only.
  • There was poor flow and capacity through the 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.
  • The department consistently failed to meet the four hour NHS constitution 4hour standard. The standard stipulates that 95% of patients be admitted, transferred or discharged within four hours. The trust did not meet the standard in any of the 12 months from February 2017 to January 2018.Performance varied between 76% in February 2017 and 89% in November 2017.
  • The trust’s urgent and emergency care Friends and Family Test performance (% recommended) was consistently worse than the England average from January 2017 to December 2017.
  • Although medical staff now completed the correct level of safeguarding both medical and nursing staff failed to meet the trust target of 85% in compliance with safeguarding training.


  • Staff were professional and cared for patients in a kind and compassionate manner. Feedback from patients and relatives was positive.
  • The department worked closely with the local Healthwatch group, they attended the monthly ‘meet the matron events’ which were attended by patients and relatives.
  • The leadership team supported staff and provided new staff with an individual induction plan and educational plans to ensure the skills they brought to the team were recognised along with identifying training needs.
  • There was consistent recording of information within the patient records reviewed. This included good completion of risk assessments and pain scores.
  • Care provided to patients suffering with sepsis (infection) was in accordance with National Institute for Health and Care Excellence guidelines. This was an improvement since our last inspection. Local audits showed good compliance with adherence to national guidelines in the management of sepsis.
  • Staff were aware of the escalation processes used in times of increased demand on the service. This was an improvement since our last inspection.
  • Streaming of patients had been introduced since our last inspection, this ensured patients were directed to the service best able to meet their needs. The streaming of patients aims to make care more efficient and take pressure away from emergency departments by having a primary healthcare professional “stream” patients coming through hospital doors, who can then refer them to primary healthcare or an emergency department.
  • Staff monitored patients who were at risk of deteriorating appropriately. Early warning scores were in use in both adult and paediatric areas.
  • The completion of the first phase of the new emergency department building was due for completion in quarter 2 of 2018/19.
  • which would mean patients were assessed and treated in a more appropriate environment, which met their needs.
  • There was adequate provision for the assessment and treatment of patients attending with a mental health illness, which ensured they were kept safe. Risk assessments of patients attending with a mental health illness were consistently completed.

Diagnostic imaging

Requires improvement

Updated 26 July 2018

We previously inspected diagnostic imaging jointly with outpatients so we cannot compare our new ratings directly with previous ratings. We rated it as requires improvement because:

  • Systems, processes and practices did not always keep people safe and safeguarded from abuse because;

Cleaning of ultrasound probes did not meet guidance presenting an infection risk.

Resuscitation equipment was not adequately monitored.

Turnover, vacancy and sickness rates were higher than the trust target.

Safety huddles were not sufficiently recorded.

  • The provider had not ensured the proper and safe use of medicines because;

Fridge temperatures were not monitored in line with trust policy.

Contrast injections used within CT were not checked by a second registered person as required by local policy and national guidance.


Following inspection, the trust provided us with assurance these issues had been dealt with and would continue to be monitored.

  • Waiting times for scans were worse than the national averages in some areas including MRI, CT, ultrasound and dexa scanning.
  • Report turnaround times for general imaging was longer than the trust target of five days. The average time from imaging to report taking seven days.
  • Changes to the process for obtaining porters to transport inpatients had resulted in delays and waits for patients.
  • There was limited space in some areas of the department for patients in wheelchairs.
  • There was no formal strategy for diagnostic imaging at the time of inspection. Although the management team had developed a draft strategy it had not been agreed or implemented.
  • There were four vacant leadership posts within diagnostic imaging. There good local leadership within the imaging department with staff consistently telling us that imaging department managers were approachable. However, staff said senior trust and directorate leaders were not visible in the department. They felt that changes were implemented without their involvement, consultation or their concerns being listened to.
  • IT systems did not support the monitoring of demand, activity and capacity across the modalities within the department.


  • The completion of mandatory training was better than the trust target overall.
  • There were quality assurance systems to monitor the safety of equipment within the department.
  • There was appropriate safety signage within the department.
  • Environmental cleaning audit results were consistently good.
  • Patient safety incidents were investigated and action was taken to monitor and improve safety. Radiation incidents were reported and monitored in line with legislation.
  • A radiation protection advisor, radiation protection supervisors and local rules were present in each modality in diagnostic imaging.
  • Chaperones were available patients were receiving care and support from a member of the opposite sex.
  • Staff demonstrated understanding of the needs of patients who were vulnerable and those who might be frightened, confused or phobic. Where patients were anxious about the process of the scan, staff made arrangements for them to visit the department prior to their appointment so they were familiar with the process and the equipment in use.
  • Staff provided patients with information leaflets and allowed time for discussion prior to procedures.
  • Volunteers were available to support patients and we observed them doing so with kindness and respect.
  • The diagnostic imaging department conducted their own patient satisfaction survey every six months. Results from the most recent survey showed that 99% of patients felt that their privacy and dignity was respected.
  • There were governance procedures in place with sufficient contact and advice for the provision of radiation protection supervisor services. There were regular radiation protection committee meetings and governance meetings and in place.



Updated 26 July 2018

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

  • There was no way of monitoring how many medical staff in outpatients were compliant with mandatory training.
  • Referral to treatment targets remained consistently worse than the national average on most pathways.
  • The response time for outpatient complaints was worse than the hospital’s target.
  • The outpatient pharmacy department could not provide assurance that turnaround times were being accurately monitored following issues with the electronic system used to track outpatient prescriptions.
  • Signage for the outpatient pharmacy was non-existent.
  • The outpatient department did not have oversight of how many medical staff had completed their mandatory training as these staff were managed by their individual speciality.


  • The service managed patient safety incidents well.
  • The trust monitored patients who could be at risk of harm from a long wait to see a clinician.
  • Staff were competent to perform their roles and received regular appraisals.
  • Staff cared for patients with compassion and feedback from patients regarding their care was continually positive.
  • Risks for the service had been identified at a service level, but wider risks such as the referral to treatment targets were not identified.
  • Staff knew and understood the hospital vision and values and told us the culture of the department was positive.
  • Staff told us their line managers and senior managers were visible and supportive.