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
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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.
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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.
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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.
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Whilst the clinical areas we visited were visibly clean in the main, compliance against national cleaning standards was found to be poor.
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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.
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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.
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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
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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.
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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.
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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
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There was a limited approach to obtaining the views of patients.
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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
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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.
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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.
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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.
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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.
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Discharge planning was inadequate and there were high levels of delayed transfers of care.
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Staff were unaware of complaints at a directorate level which had influenced change.
Well-led
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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.
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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.
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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.
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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.
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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.
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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.
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There was a significant delay or lack of response in acting upon recommendations made from external reports which were specifically related to mortality reviews.
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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.
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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:
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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.
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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.
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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.
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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.
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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