Medway Maritime Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This meant we looked for evidence that people were protected from abuse and avoidable harm. We assessed 8 quality statements.

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected when this was in their best interests and in line with legislation.

At our last assessment we rated this key question inadequate. At this assessment, the rating has improved to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was a risk that people could be harmed, but we saw improvements had been made.

The service was still in breach of the legal regulation in relation to safe care and treatment. This was in relation to patient risk assessments not being completed, safe management of medicines and systems and processes for patients attending with mental health needs.

People were not always protected or kept safe. Staff understood the risks but could not always manage them effectively, often due to staffing challenges during busy periods. Although staff had the right skills, qualifications and experience, they were challenged to consistently deliver safe care during busy periods.

Staff did not always report incidents due to time pressures, and medicines were not consistently well-managed. Facilities and equipment generally met people’s needs, but the Clinical Decision Unit (CDU) fell short. While the environment was clean and well-maintained, not all risks were fully mitigated. Completion rates for staff training and appraisals were sometimes below trust targets for some staff groups.

The service did not always maintain a positive learning culture. Staff did not always report all incidents. However, staff felt able to raise concerns and managers investigated incidents thoroughly.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed some shortfalls. The service did not always promote a proactive and positive safety culture rooted in openness and honesty. Staff did not always report patient safety events. Leaders did not always embed learning to drive continuous improvement and good practice. These shortfalls limited the service’s ability to learn from incidents and improve safety.

Staff did not consistently report incidents. They told us time pressures impacted their ability to do so, and managers acknowledged these constraints. This led to missed opportunities for learning and improvement.

Since 2024, the service had experienced a continued rise in security-related concerns. Some staff said they did not always feel safe and have not received feedback after submitting incident reports. They expressed concern that leaders had not acted on these reports. However, following the on-site assessment, leaders demonstrated a process that showed how staff could access incident investigation progress. This meant that a process was available to staff, but they were not always aware of its availability.

We escalated this to senior leaders, who confirmed that the security team was assessing the issue. However, despite a system being available to staff to access incident investigation progress, staff did not always know what actions were taken to effectively reduce the number of security related concerns.

Mandatory training rates for medical staff were 77% over the past 12 months prior to our assessment. This was below the trust target of 85%. Mandatory training rates for nursing staff were 91% over the past 12 months prior to our assessment. The was above the trust target.

Staff understood how to report incidents and described their managers as approachable. Managers investigated patient safety events appropriately and followed the Patient Safety Incident Response Framework (PSIRF). They presented incidents to the weekly Incident Review Group, which determined whether to conduct a local learning response or escalate for further review. PSIRF, is a mandatory framework within the NHS in England for how health services respond to and learn from patient safety incidents.

Learning had been taken and shared with staff following incidents within the department. Learning responses resulting from patient safety events demonstrated a good level of family and patient involvement in the investigation of patient safety events. Families and patients were given the opportunity to ask questions as part of the investigation. Patients and their families received copies of the final report.

Managers shared learning and outcomes with staff by email and during meetings, which helped foster a learning culture. Staff gave examples of changes made in response to safety incidents. For example, the service increased the frequency of reviews for patients waiting for psychological assessment or a mental health bed at the local NHS mental health trust. Leaders also improved the process for requesting one-to-one care to reduce the risk of harm.

When things went wrong, staff apologised and provided patients with honest information and appropriate support.

The evidence showed some shortfalls. The service did not consistently work in partnership with people to establish and maintain safe systems of care. Staff did not always manage or monitor patients’ safety effectively. They did not always ensure continuity of care, particularly when patients moved between different areas of the department or between services. However, staff worked well with system partners to support care delivery.

Patients experienced delays in receiving treatment and staff gave treatment in unsuitable areas of the department. Lack of flow in the department compromised patient safety. Poor flow meant that patients who needed to be admitted to wards could not be seen within acceptable timeframes. Crowding in the department remained a concern. Patients often stayed for extended periods while waiting for a ward placement, including in areas not designed for inpatient care. Staff managed patients needing admission or specialist review in waiting rooms and temporary escalation areas such as majors and area 3, due to the emergency department operating at full capacity.

We received mixed feedback about how well different specialties worked together. Staff did not always coordinate care effectively across teams.

Waiting times for referral, treatment, admission and discharge did not meet national standards. On the day of our assessment 39 patients had waited more than 12 hours in the department. A further 37 patients awaited admission to wards following their medical review but were unable to move due to a lack of beds on wards. The longest waits were 40 hours for admission.

During our previous assessment in February 2024, we found patients being cared for in the main corridor. At this assessment, the service had stopped using the corridor and instead placed patients in temporary bed spaces in majors. Leaders told us this improved staff visibility of patients. However, we continued to observe concerns about patient privacy, dignity and staff’s ability to meet patients’ needs. We observed instances when patients were unable to access the toilet independently and had to use portable bottles in temporary escalation areas.

Staff told us they could not always monitor patients safely when they remained in the department for extended periods. They did not always report these incidents, and we found that nursing assessments were not always completed.

Some patients left the department before receiving treatment due to long waits. This occurred more frequently in majors, area 3 and the clinical decision unit (CDU). Data showed between May 2024 and January 2025 an average of 241 patients a month left before being seen which was mostly in line with the national average.

Staff experienced challenges managing patients with mental health needs who were waiting for psychological assessment or a bed at the local NHS mental health trust. Managers said they had good working relationships with the trust but still faced frequent delays. These delays had led to patient safety events, including patient harm. Although departmental leaders listened and tried to make improvements no sustainable improvement had occurred.

The service had 24-hour access to adult mental health liaison and specialist support. Staff from the liaison team triaged patients between 1pm and 10pm, and managers planned to extend these hours once staffing improved. Staff followed clear pathways for patients with mental health needs.

Paediatric-trained staff triaged children arriving at the emergency department. The service saw around 100 children each day. Staff followed clear processes and could refer children to a GP service when appropriate. We observed positive working relationships between the paediatric department and other areas.

The trust worked collaboratively with the local NHS ambulance trust to improve ambulance handover times and met the 15-minute handover target. This helped ambulances return to the community more quickly.

Staff acted as clinical navigators at the entrance to the department for triage and flow diversion purposes. They assessed patients in area 1 and 2 before directing patients into areas that were deemed suitable following the triage process.

The evidence showed a good standard. The service worked effectively with people and healthcare partners to understand what safety meant to them and how best to achieve it. Staff focused on improving people’s lives while protecting their right to live free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They shared concerns quickly and appropriately.

Staff and managers used clear systems, processes and practices to protect people from abuse, neglect and harassment. Safeguarding policies for adults and children reflected national guidance and best practice. These policies clearly outlined the steps staff should follow. Managers and staff understood their safeguarding responsibilities.

Staff completed safeguarding training appropriate to their roles. Compliance for safeguarding adults level 1 and 2, and safeguarding children level 1, 2 and 3, met or were mostly in line with the trust target of 85%. Staff also completed training on the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS), with compliance at 84%. Although safeguarding children level 3 training compliance was below target at 75%, managers confirmed this was improving. Staff demonstrated a good understanding of MCA and DoLS in their daily practice.

The service provided in-house training on restraint and de-escalation techniques. Staff and security personnel used these skills to support patients who displayed behaviour that challenged. Staff told us they were encouraged to use conflict resolution techniques instead of restraint. When restraint was used, staff ensured it was lawful, necessary, proportionate and safe. They remained committed to reducing the use of restrictive interventions.

Staff accessed the safeguarding team for advice and support when needed. Managers attended monthly trust safeguarding meetings to review cases and share learning.

Staff supported people to understand what keeping safe meant. They encouraged and empowered patients to raise concerns and provided support when people felt unsafe or had experienced abuse or neglect.

Staff responded attentively to patients in distress. They used therapeutic approaches to support patients waiting for mental health assessments.

The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Patients attending the department often experienced long waits, which increased the risk of deterioration. Between May 2024 and April 2025, 13% of patients waited more than 12 hours.

Staff triaged patients to be seen in order of clinical need using a national clinical assessment tool. Patients with a higher acuity were reviewed first and prioritised within the department. However, staff did not consistently complete initial triage within 15 minutes of arrival in line with national guidance. Between May 2024 and April 2025, only 55% of patients were triaged within 15 minutes of arrival.

Staff did not always complete risk assessments. During our two-day assessment, we reviewed 10 patient records each day. On day 1, we found missing risk assessments in 4 of the 10 records. We escalated this to leaders, who acted on our feedback. On day 2, we reviewed 10 patient records, and all included the correct risk assessments.

At the time of our assessment, patients were staying overnight in the Same Day Emergency Care (SDEC) unit. Staff had not completed inpatient risk assessments for these patients as they were unaware, they could access the computer programme that gave them access to the nursing assessment templates. This meant that patients did not always have their needs assessed and they were at risk of developing avoidable harm. For example, pressure ulcer prevention assessments were important if patients were only being nursed on trolleys as this risk would have been increased.

Following our assessment, leaders helped staff understand how to enable the electronic patient record (EPR) functionality to allow staff to complete and record risk assessments. Risk assessments included, pressure areas, falls, moving and handling, and bed rail assessments for patients with a decision to admit to a ward. Staff could also complete dementia and delirium screening, malnutrition universal screening tool (MUST), and International Dysphagia Diet Standardisation Initiative (IDDSI) assessments.

Staff caring for patients with mental health needs used the Safeguarding and Managing Risk Tool (SMaRT) to assess risk. They requested support from the psychiatric liaison team to carry out observations and arranged one-to-one staffing for patients assessed as amber or red risk.

Staff referred patients who required mental health advocacy to the local NHS mental health trust for assessment and support. These processes were well embedded, although some cases experienced delays.

Staff in the Clinical Decision Unit (CDU) observed patients while waiting for the trust’s enhanced care team to respond. The nurse in charge escalated concerns through the safer staffing huddle when additional support was needed.

Staff advocated for patients. They encouraged family members to be present and supported them to ask questions. For example, a husband raised concerns about his wife’s social care support following a previous discharge.

Staff advocated for patients without family support, monitored high intensity users, held multidisciplinary meetings and worked with community services to provide advocacy.

Department managers and matrons completed daily assurance reports, reviewing at least 5 patients per day. These checks included wristbands, vital signs, care plans, handover sheets, risk assessments for falls and pressure ulcers, medications, refreshments, infection prevention and control (IPC), and updates for relatives. We sampled records from the previous 6 months and found good compliance. Staff escalated any gaps to the appropriate team or manager on duty.

Staff and managers responded to complaints related to risk. The service welcomed patient feedback and had clear complaint procedures.

Staff respected people’s wishes regarding treatment. They explained alternatives when patients declined treatment and considered advanced care plans. Staff identified Do Not Attempt Cardiopulmonary Resuscitation orders early, either during triage or in partnership with ambulance services.

The evidence showed a good standard. The service consistently detected and control risks in the care environment. Staff ensured that equipment, facilities and technology supported the safe delivery of care.

When the department became crowded, staff cared for patients in areas not designed for extended stays. These areas lacked shower facilities. Staff used the Clinical Decision Unit (CDU) to care for patients awaiting mental health assessments or mental health beds. The CDU did not have beds or privacy curtains. Staff provided reclining chairs and offered bedding on request. When patients required a shower, staff escorted them to a ward with appropriate facilities.

In March 2025, the trust’s estates team completed a fire risk assessment and identified 9 risks. These included blocked escape routes, obstructed fire call points and exits, and inappropriate equipment placement. The team also raised concerns about chemical hazards due to corridor-based care and staff not following fire safety guidance. Following this, the department passed a follow-up fire safety inspection.

The department including the CDU met the standards set by the Psychiatric Liaison Accreditation Network (PLAN) and held PLAN accreditation.

The CDU which cared for patients attending with mental health needs did not have locked doors, as the department was not legally permitted to restrict exit. Patients frequently left the area using the door release, despite staff encouraging them to stay. Leaders told us they were exploring lawful options to prevent patients at risk of harm from leaving. If patients were assessed as a high risk, staff would stay with them in the hospital grounds when possible and security would be called to assist if needed.

Managers confirmed that funding had been approved to build a dedicated mental health hub on the hospital site. This would provide a safer and more appropriate space for patients with mental health needs, separate from the emergency department. However, the hub was not expected to be operational for several years.

The department’s layout and design generally aligned with best practice and legislative requirements. It comprised of 7 areas, Resuscitation, Areas 1, 2 and 3, Majors, CDU, the Paediatric Unit and a Rapid Assessment Unit (RAU). Ambulances and walk-in patients used separate entrances. The resuscitation area included 9 bays for critical care. Areas 1, 2 and 3 provided seating for patients who could mobilise.

The majors department had 19 cubicles. During full capacity protocol, staff could add 17 temporary care spaces. Each space had a call bell and signage identifying the named nurse responsible for care.

The paediatric unit featured private treatment cubicles and a large play area visible from the nursing station. Signage throughout the department was clear.

Seven televisions displayed triage waiting times and time spent in the department.

Staff had access to private spaces, including a mental health assessment room, bereavement room, dignity room, staff room, private office and seminar space.

The service-maintained resuscitation trolleys in 4 locations: RAU, Majors, Urgent Treatment Centre (UTC) and Area 3. Between March and May 2025, staff mostly completed daily checks of emergency equipment and escalated concerns appropriately. Staff also checked fridges, sluice rooms, commodes, call bells and oxygen cylinders in temporary care areas, and escalated any concerns.

The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs. However, they did make sure staff received effective support, supervision and development.

Consultant cover did not meet the recommendations of The Royal College of Emergency Medicine. Consultants were available from 8am to 10.30pm on weekdays and 8am to 10pm at weekends, then on-call. National guidance states consultant cover should be between 8am and midnight then on-call.

Of the 13 full-time equivalent (FTE) consultants, 11 were completely clinical, while 2 had reduced clinical duties or were focused on education. On average, 3 consultants worked in the morning, reducing to 2 by 9pm and 1 by 11pm. At weekends, only 1 consultant was present in the morning and afternoon.

Consultants told us this was insufficient and recommended recruiting additional FTEs to meet demand.

Department managers relied on nurses from other wards to assist with patients in temporary escalation areas during full-capacity periods, but this did not always happen, as staff were not always willing or able to assist. Support from bank or agency staff varied between shifts. Staff told us this increased pressure and sometimes led to poor care for patients in temporary escalation areas.

Some nurses described the situation as emotionally difficult and said they felt unable to provide optimal care.

The paediatric department had a shortage of senior nursing staff. Of the 16 nurses available, only 1 held a senior leadership role. Junior staff said the lack of senior structure affected teaching and training. However, leaders told us that the Band 7 senior nurse was supported by a Band 8 nursing leader who oversaw the department and reinforced the leadership structure

Each CDU shift included a registered mental health nurse (RMN) and a clinical support worker. At the time of our assessment, managers did not directly employ RMNs. However, the trust has now successfully recruited 1 RMN to work in the department and further recruitment remains ongoing.

Clinical support workers received training in the management of violence and aggression, mental health observations, and restraint training. However, this did not always meet the advanced needs of some patients with mental health needs.

When RMN shifts could not be filled, managers assigned a second registered general nurse (RN). Data showed between February and April 2025 that 13% of shifts did not have a RMN. Staff raised concerns about this stating they lacked the training to safely support people in distress. Although mental health modules were included in mandatory training, staff felt this was not sufficient.

To address this, department managers worked with the local NHS mental health trust to recruit 5.2 whole-time equivalent (WTE) RMNs. This formed part of a wider programme to improve mental health staffing across the hospital.

Managers completed quality and safety logs 4 times every 24 hours. Our review of logs since January 2025 showed that staffing levels frequently fell below agreed staffing levels. When this happened, managers recorded actions taken to reduce risk in the shift report.

Managers used heat maps and planning tools to predict staffing needs, but we did not see evidence of resulting actions. They reviewed nursing gaps 2 weeks in advance and attempted to move staff internally. If this was not possible, they referred gaps to the hospital’s temporary staffing team. However, this did not always result in cover being provided.

Managers attended the weekday Medicine and Emergency Care (MEC) huddle at 8.30am to discuss staffing across the division. When 10 or more patients were in temporary escalation areas, managers asked ward staff to support the emergency department. The number of staff moved depended on patient numbers and ward capacity. Managers also attended a 3pm huddle to plan for the night shift and shared plans with the hospital site team.

On Fridays, the matron team reviewed weekend staffing and escalated concerns if extra staff were needed. Department managers monitored staffing throughout the weekend and escalated risks when levels were too low to run the department safely.

In April 2025, appraisal compliance for medical staff and nursing staff was slightly below the trust target of 90%. The department had not met this target for the past 12 months.

Mandatory training rates for medical staff were 77% over the past 12 months prior to our assessment. This was below the trust target of 85%. Mandatory training rates for nursing staff were 91% over the past 12 months prior to our assessment. This was above the trust target.

The recruitment process ensured all staff, including agency staff, were suitably experienced, competent and able to carry out their role.

The evidence showed a good standard. The service mostly assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff consistently used “I am clean” stickers with accurate dates on newly cleaned equipment. We saw this practice across the department.

The service had an effective approach to assessing and managing infection risk, in line with national guidance. Staff completed weekly Infection Prevention and Control (IPC) audits across 5 areas of the emergency department. In April 2025, the department achieved an average compliance score of 98%, meeting the expected standard. Staff also completed commode observation audits, with 100% compliance recorded in April 2025.

Housekeeping staff completed daily cleaning checklists for 5 areas of the department, including kitchen spaces. In April 2025, they recorded good levels of compliance.

Staff kept premises and equipment clean and hygienic, which helped protect people from infection risks. They supported people to maintain personal hygiene in line with their individual needs and preferences.

The service had clear roles, responsibilities and procedures for IPC, which followed national guidance. Staff received training and understood their responsibilities for maintaining high standards of cleanliness and hygiene, including personal and hand hygiene.

Staff shared infection risk information appropriately with external agencies, people using the service and visitors. They supported people to understand and follow IPC measures. IPC staff worked closely with the trust’s communications team to ensure key messages were shared across the organisation.

Staff understood and followed food safety and hygiene standards when preparing or handling food.

Staff mostly used personal protective equipment (PPE) that met national guidance and matched the level of infection risk and care being delivered.

The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Systems and processes for managing and administering medicines were not always safe. We were not assured that staff consistently prescribed medicines correctly or administered them safely.

Staff used an electronic prescription and medicines administration system (ePMA) in the emergency department (ED). However, this system did not integrate with the electronic medicines cabinets. As a result, staff did not use many of the cabinets’ safety features. We observed staff preparing medicines in the clinic room without referencing the prescription record, which increased the risk of errors.

The pharmacy department did not provide direct clinical support to the ED. The department lacked a dedicated pharmacy resource, and the level of support did not meet national guidance from the Royal College of Emergency Medicine. This limited oversight increased the risk of medicine-related incidents.

The service did not have a fast-track process for sending prescriptions from the ED to the pharmacy. Staff told us that this caused delays in obtaining medicines that were not held in stock. Leaders told us after the on-site assessment that staff could call the pharmacy directly during working hours to request urgent items when needed.

During our assessment, we observed several prescribing errors and near misses. Staff identified these before they affected patients, but they did not record the incidents. Staff told us these errors were common and attributed them to the system’s lack of safeguards for detecting duplicate prescriptions or unusual doses. When we requested evidence of near miss or error reporting, the provider was unable to supply any. We were not assured that the provider was accurately recording incidents or learning from them to prevent recurrence.

Staff did not routinely complete medicines reconciliation for patients in the ED, including those who stayed for extended periods. This increased the risk of patients missing regularly prescribed medicines. Medication reconciliation is the process of comparing a patient's medication orders to all the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or medicine interactions.

However, staff recognised the importance of time-critical medicines, such as those for treating Parkinson’s disease, and had processes to identify these patients and ensure timely administration.

Staff followed national guidelines for the timely administration of medicines to treat sepsis, and we saw evidence that this target was consistently met.

Staff demonstrated good knowledge of medicines administration and safety. They disposed of medicines appropriately, and we found no evidence of covert medication practices.