Medway Maritime Hospital

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• 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

Patients did not receive a consistently safe service. Large numbers of patients resulted in overcrowding and patients accommodated in non-designated care areas. The service did not always have enough staff for the number and acuity of patients. Processes did not support staff to deliver safe care or treatment. The policies to guide staff to mitigate overcrowding, lack of patient flow and staffing concerns were not clear. Medicines were not managed well, and patients did not always receive their medicines on time. The service did not always learn from incidents as not all incidents were reported and acted on. However, the service had an improvement plan and participated in Health and Care Partnership and system level workstreams to support patient flow.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Some people told us they had poor experiences in the department. Between 31 August 2023 and 4 April 2024, Care Quality Commission (CQC) received information of concern from 21 patients or their relatives. Common themes included patients’ privacy and dignity not being protected, lack of staff availability, long waiting times and patients accommodated in the corridor (in non-designated care areas) for several days. The Friends and Family Test for 1 December 2023 to 28 February 2024 showed similar themes. The trust investigated and responded to complaints, but some patients continued to have poor experiences in the department.

Staff said there was a culture of not reporting incidents in the department. Some staff said they were discouraged from raising concerns about the safety of the service. Staff and managers told us they did not always submit an incident report when patients in the corridor exceeded target waiting times or when they were concerned about staffing levels or felt the department was over capacity. Staff said non-clinical work was sometimes cancelled due to operational pressures . This, and some incidents being unreported meant there was a lack of opportunity to review, investigate and share learning from some types of incidents with department staff. Some staff said that learning from incidents was shared with them, but others disagreed. However, senior leaders told us the trust had a centralised patient safety improvement team who investigated and shared learnings from incidents.

The trust had a Patient Safety Incident Response policy to support staff to report incidents, this aligned to NHS England guidance on recording patient safety events. The trust provided us with several policies, including the trust’s Safe Staffing Escalation policy which directed staff to submit an incident report when staffing fell short of patient acuity and could not be mitigated. We reviewed the National Reporting and Learning System (NRLS) from August 2023 to November 2023 and found no incidents of this nature reported. We brought this to the attention of senior leaders, who told us incidents relating to 12-hour breaches and staffing were reported locally and only when they could not be mitigated, for example by moving staff from the wards to support. They told us that the trust’s Safe Staffing Escalation policy had been superseded by the trust transitioning to the new Patient Safety Incident Reporting Framework (PSIRF). Senior leaders provided local incident data which showed that between November 2023 and February 2024 a total of 242 incidents were reported by emergency department staff on the new incident reporting system. Of these, 67% were 12-hour breaches. However, from 1 October 2023 to 31 March 2024 only 12 staffing incidents were reported, which was inconsistent with feedback from staff and patients. However, the service had an improvement plan with initiatives to reduce ambulance handovers and unnecessary attendances, provide same day emergency care (SDEC), optimise bed capacity using IT solutions and improve discharge times through electronic discharge notes.

The service had pathways and processes to guide staff; however, these did not always support timely and safe care and treatment. Patients were generally triaged quickly, but often had to wait several hours to be assessed and provided with a treatment plan from a clinician. Patients who needed to be admitted to an inpatient bed often experienced delays and extended stays in the emergency department. Delays of admission to an inpatient bed and ongoing treatment can increase the risk of harm and possible death. However, the service did have a process whereby admitting teams reviewed and arranged treatment plans for patients in the emergency department and processes were in place to ensure effective and timely handover of patient information when patients were admitted to inpatient areas. The service had worked with the local NHS Ambulance Trust to improve handover times for patients arriving by ambulance and the trust performed well against national targets for ambulance handover.

Staff told us the trust guidance lacked clarity and did not specify maximum patient numbers in non-designated care areas. Staff told us this made it more difficult to staff according to patient demand. During the on-site assessment, staff demonstrated commitment to providing safe care. They described examples of the way they worked to provide safe systems of care, but many said they felt overwhelmed by the overcrowding and said as a result, patient safety was compromised. Senior leaders told us guidance was provided to support safe systems and pathways, which included system wide workstreams to improve patient flow through the hospital and therefore improve patient experience and safety in the emergency department. They told us it was difficult to specifying maximum patient levels as this was a complex decision-making process and dependent upon patient acuity, other system demands, and staffing availability. Following the assessment, the Trust consolidated previously conflicting policies into 2 clear policies providing staff with improved guidance.

The service worked collaboratively with local system partners, including the local NHS Ambulance Trust, local community, and mental health care trusts, stakeholders and commissioners. Partners told us the trust collaborated on the development of processes and pathways to support patients to receive safe care and treatment in a timely manner in the emergency department. This included working with the local NHS Ambulance Trust to embed a pathway to improve handover of patients from ambulances to emergency department staff and working with all partners to develop pathways to redirect patients away from the emergency department to release capacity in the department.

Staff did not have clear processes to refer to and guide them to mitigate risks which related to overcrowding and lack of patients flow through the department. The trust provided 7 guidance documents relating to the management of patient flow. The guidance was conflicting, with some documents in draft and others having expired review dates. There was no single document to guide staff about how to safely accommodate patients in non-designated care areas. However, the service did have pathways for specific conditions and injuries which referenced national guidance. Systems to stream patients to the appropriate area of the Emergency Department or to other services were used effectively. Following the assessment, the trust introduced a new trust-wide Full Capacity Protocol policy and revised ED Prevention of Emergency Arrivals Experiencing Delays to Assessment or Treatment policy.

Patients, relatives and staff contacted us prior to the assessment process to tell us that staff did not always protect patients from degrading experiences. Examples included frail patients who could not get up and take themselves to the toilet were left to soil themselves and left in soiled clothing and bedclothes for hours. Other examples included medicines not given, no offers of mobilisation, body washes, pressure area care or conversation stimulus. However, feedback from patients during the on-site assessment was positive, with patients saying they felt safe and well cared for.

Staff reported that frail, bed-bound patients had been told to soil themselves because there were not enough staff to take them to the toilet. Patients were stranded in ED for 50 hours or more, with no access to wash facilities. There was a lack of pillows and blankets for patients, including those located on trolleys close to the ambulance entrance and patients were left in their soiled clothing, and medications not given. However, during the on-site assessment staff described how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Ambulance crews worked with the emergency department staff to highlight safeguarding concerns to the staff and safeguarding team when handing over the care of patients. Staff described the safeguarding training they received and completed. This included safeguarding levels 1, 2 and 3 (role dependent) for both adults and children, and training about the Mental Capacity Act, female genital mutilation, child exploitation and preventing radicalisation (Prevent). Managers stated the trust had defined recruitment pathways and procedures to ensure the relevant recruitment checks had been completed for all staff. These included disclosure and barring service (DBS) checks prior to appointment.

The Trust had an Adult Safeguarding policy which referenced relevant national and local guidance such as the Royal College of Nursing Adult Safeguarding Roles and Competencies for Health Care Staff and the Kent and Medway Safeguarding Adults – Multi-Agency Safeguarding Adults policy. Training included safeguarding adults levels 1, 2 and 3, safeguarding children, levels 1, 2 and 3, Mental Capacity Act (MCA) and associated Deprivation of Liberty Safeguards (DoLS) and preventing radicalisation (Prevent) training. Records provided by the trust showed staff compliance for safeguarding adults levels 1 and 2, safeguarding children level 1 and preventing radicalisation training met the trust target of 85%; however, training for MCA, DoLS, safeguarding adults level 3 and safeguarding children levels 2 and 3 did not meet the trust target. Additional data provided by the trust showed, that despite the trust targets not being met, improvements were being made with more staff completing this training.

There were mixed views from patients about their involvement in managing their conditions and risks. Some patients told us that staff did not keep them informed about their conditions and treatment, nor did they consider their knowledge of their own conditions, which included how to manage them. However, other patients said staff did keep them informed and did consider their knowledge.

During the on-site assessment some staff said that, because of overcrowding and lack of staff, sometimes it was not possible to monitor patients’ health in a timely manner.

There were no concerns raised from system partners about the management of risks in the Urgent and Emergency Service.

Staff did not always complete patient risk assessments and observations at the correct frequency. The trust audit of patient records for October 2023 showed that staff did not always complete skin integrity risk assessments or hourly safety checks and did not always detail how frequently patient observations needed to be done. However, the service used the National Early Warning Score (NEWS2) to assess illness severity and risks of patient deterioration. Trust NEWS2 audits for December 2023 and January 2024 showed most staff completed these accurately and escalated deteriorating patients appropriately. Patient records viewed on the day of the site visit showed patient risks were identified and relevant actions were taken.

Some patient advocates raised safety concerns about the environment. Concerns included patients not having specialist nutrition and hydration needs met and patients on trolleys in the corridor for several days who may be at higher risk of developing pressure ulcers.

Staff were concerned about fire escape routes being blocked because of accommodating patients in the corridor. However, senior leaders told us the fire brigade had undertaken reviews and an unannounced inspection of the department and were satisfied with fire safety arrangements. During the on-site assessment no concerns were identified. Staff also raised concerns about risk to patients’ skin integrity because patients were accommodated on hard trolleys for extended periods of time rather than on beds. Staff told us about a lack of call bells for patients accommodated in the corridor. They told us call bells had been provided that morning in this area. Senior leaders told us staff working in the corridor were alerted to a patient call bell by reviewing a panel in majors, or staff in majors would inform those in the corridor if not answered promptly. While call bells were available, there was an increased risk, because of the location of the call bell panel, that patients in the corridor could not obtain timely support. Senior leaders told us that in the 7 months prior to the assessment the use of the corridor to accommodate patients had become a regular feature due to challenges with patient demand and flow. Since the inspection senior leaders decided to stop using the corridor to accommodate patients. This resolved call bell issues; however, some staff told us this resulted in the use of other undesignated care areas in the emergency department such as majors and resuscitation, and some of the same concerns remained. This meant we could not be assured the risk to patients had been minimised. Staff also spoke about the lack of an appropriate environment for patients who presented to the department with mental health conditions. They described the clinical decision unit, which accommodated patients presenting with mental health conditions as not being a therapeutic space.

The environment within the emergency department was not suitable for the number of people being accommodated in the department. During the on-site assessment on 21 February 2024, we observed patients being accommodated in non-designated care areas. These areas did not have the facilities and infrastructure to provide safe care and treatment. Fourteen patients were accommodated in the resuscitation area despite there only being 9 designated patient care areas. There were 19 patients in the major's area, where there were only 10 designated care areas. There were 15 patients in the corridor where there were no designated patient care areas. The environment, specifically the corridor, did not support safe care and treatment. This was because the layout of the corridor was an L shape, which did not support staff to visually monitor and observe patients, especially at times of staff shortages. The call bell system in the corridor area relied on staff from the corridor going into majors, or staff from major's alerting corridor staff to where the call was originating from. Although staff expressed concerns about risk of fire safety because of overcrowding in the department, there were no identifiable fire safety risks observed on the day of the on-site assessment. The service had identified the clinical decision unit (CDU) to accommodate patients presenting with mental health conditions while waiting for assessment or mental health inpatient beds. The CDU area had chairs but no beds. There was a Safe Haven next to the emergency department, designed specifically for low-risk patients experiencing mental health crisis.

The trust’s winter measures fire risk assessment identified risks relating to fire safety because of overcrowding and the use of non-designated care areas. Risks included obstructed escape routes due to patients in corridors and visitors placing seats across emergency exits. Lodging beds in examination and assessment areas obstructing escape routes. Fire alarm panels; call points and extinguishers being obstructed by equipment or people, and staff ignoring fire safety rules. The fire risk assessment detailed actions to be taken with immediate effect to lessen risks to patients and staff. The ED risk register referenced risk to patients because of overcrowding and use of non-designated areas of care. Risks identified by the service included risks of suboptimal care, monitoring and recognition of the deteriorating patient, infection prevention and control, development of pressure ulcers and compromised clinical assessments. The trust had mitigations in place to reduce the risk. The risk register stated when risks needed to be reviewed. Governance meeting records showed risks were reviewed as part of that process. Information provided by the service showed harm to patients resulting from the environment had not been identified. Senior managers told us that following the assessment the trust had undertaken harm reviews for patients who had stays of over 12 hours in the emergency department. This included reviews by the tissue viability team for patients who developed pressure ulcers. This was to support identification of environmental issues, such as patients being accommodated for long periods of time on trolleys that may have caused harm to the patient.

Between 31 August 2023 and 4 April 2024, we received information from 6 patients, relatives or carers describing their experiences which included a perceived lack of staff to provide care and treatment. Feedback included: “Staff had no time to support with giving fluids.” They said, “Very little care, I only saw 1 care support worker and registered nurse at any time.” They said, “Staff were crying on the phone for help, no one seemed to turn up.”, Patients said "They had been left sitting in their own faeces all day because there was no one available to help.” and “Elderly patients are left for hours in ED without being checked on.” The Friends and Family Test for 1 December 2023 to 28 February 2024 showed some patients experienced insufficient staff to provide care and treatment. Comments included “Staff were overworked and could not care properly for the number of patients there were.”, “No staff responsible for corridor patients.”, “No one to contact when in trouble.”, “I only attracted staff by grabbing a passing person not even allocated to that area, all hit and miss, mostly miss.” However, other patients commented positively about the availability of staff. Comments included “Quick to be seen.”, “I was treated promptly and efficiently.”, and “Very speedy and efficient service.” These comments indicated these patients did not experience a shortage of staff.

Between 31 August 2023 and 4 April 2024, we received information from 6 members of staff who reported a shortage of qualified nursing staff working in ED which resulted in delays to patient care. This included patients in corridors not receiving any direct care overnight. During the on-site assessment on 21 February 2024, staff said that due to insufficient staffing and overcrowding, patients did not always receive the clinical observations they required. Nurses working in the major's area said they felt under pressure, they were trying to manage and treat patients, but felt they were not able to give the best care due to lack of staff to care for the additional patients. Some medical staff told us the emergency department did not have enough medical staff. They said the number of consultants employed did not meet the Royal College of Emergency Medicine (RCEM) guidelines. A member of the medical team told us the overcrowding and lack of staff resulted in a lack of monitoring of patients, with staff only having capacity to carry out periodic clinical observations on patients. However, senior leaders told us they had completed a staffing review, and that the department was adequately staffed against the budget. The department received staff from wards when there were staff shortages and there were no instances when there had not been direct care provided for patients overnight. They had completed a review of consultant numbers and provision of clinical activity, this showed that the service did meet the RCEM guidelines.

During the on-site assessment on 21 February 2024, we observed 2 care support workers looking after patients in the corridor. They had to actively seek out a registered nurse for support when patients required pain relief and medicines. We did not observe a registered nurse actively overseeing the care provided to patients in the corridor. However, senior leaders told us that although at the start of the shift there was no registered nurse available to be allocated in the corridor, 2 nurses from wards were sourced with the first providing nursing care to patients in the corridor from 9:30am.

The service shared data from November 2023 which showed there were unfilled shifts across nursing, care support workers and mental health nurses throughout the month. More recent information for weeks beginning Monday 19 February and Monday 26 February 2024 showed staffing gaps continued with staff shortages ranging from 1 to 7 staff members. Senior leaders told us the department’s staffing was over established and the department was a net receiver of staff from other wards in the hospital when there were staff shortages. However, it was evident from other staff feedback that this process still did not ensure sufficient staffing to meet patient’s needs. The guidance about how many staff and of what role were needed to safely care for patients accommodated in non-designated care areas was unclear. Staff shared a Quality Impact Assessment for the Prevention of Emergency Department Arrivals Experiencing Delays to Assessment or Treatment. This detailed there should be an additional nurse for every 6 patients accommodated in the corridor area. This was not the case on the day of our on-site assessment. There was no information about additional staff requirements to meet the needs of patients accommodated in the other non-designated care areas, such as in the resuscitation or major's areas. It was not possible to establish how many consultants were on duty each day. The service provided the medical staff duty rota for January and February 2024. This showed there were 15 consultants but did not detail their working schedule. However, senior leaders told us they had completed an assessment of medical staffing against Royal College of Emergency Medicine (RCEM) standards in 2021 and the establishment of medical staffing was adequate at the time of the review. A further review of medical staffing against the RCEM guidelines was due to be completed by June 2024.

Patients provided feedback via the Friends and Family Test. The comments about the cleanliness of the emergency department, included 2 themes. The first was the cleanliness of the toilets, with some patients having to use toilets they did not consider to be clean. The second theme was about the risk to patients who were waiting in the department with compromised immune systems because of cancer treatment. However, patients on the day of our site visit did not express any concerns with the cleanliness of the department.

Housekeeping staff spoke about the challenges they faced with being able to clean effectively. They said they could not clean effectively because of the cramped conditions when there were additional patients in the department, as it was impossible to clean around all patients and equipment. Staff expressed concerns about the management of patients undergoing chemotherapy who presented at the emergency department with suspected sepsis. However, senior leaders told us that ambulatory patients who present to the department do so at the Urgent Treatment Centre (UTC) front door. Here, a senior member of staff streams all patients who attend and if suspected to have sepsis they would have a full assessment by a triage nurse, including sepsis screen.

The environment as observed during the on-site assessment was visibly clean. However, the environment was cramped and crowded with patients which increased the risk of ineffective cleaning. The proximity of patients in waiting areas and in areas where additional patients were accommodated in non-designated care areas, increased the risk of cross contamination. We observed most staff followed good infection prevention and control practices, including use of personal protective equipment and handwashing. However, some poor practices were observed which included some medical staff not using personal protective equipment when attending/examining patients, staff not using personal protective equipment when handling used linen and some staff not changing gloves between patient contacts.

The trust and the emergency department followed the NHS England national infection prevention and control manual (NIPCM) for England. There was a system of regular audits of cleanliness and infection and prevention control practices. Where audits identified targets were not met, there was a process of repeated audits to ensure compliance and cleanliness, and infection control and infection practices improved. Staff had expressed concerns about the management of patients undergoing chemotherapy who presented at the emergency department with suspected sepsis, however Senior leaders told us that although there was no formal pathway, there was a prioritised system of flagging patients having cancer treatment to the Acute Oncology Service (AOS) who would then review the patient within 1 hour of being in ED and recommend onward treatment.

The Friends and Family Test (FFT) detailed patients having waited long periods of time for pain relief, sometimes up to 7 hours. Reasons included that patients had not yet been assessed by a doctor and therefore no pain relief had been prescribed, or that staff were too busy to provide pain relief. Patients receiving treatment within ED did not always receive antibiotics promptly. Trust sepsis audits showed that between April 2023 and December 2023 only 68% of patients with suspected sepsis received intravenous antibiotics within the 1-hour national guidance. On the day of the on-site assessment there was mixed feedback from patients about the timeliness of medicine administration. One patient said staff did not give them pain-relieving medicines as needed. A second patient said they had to wait for 2 hours after asking for pain relief before receiving it. However, other patients said they received their medicines as and when they needed them.

Staff contacted us to share their experiences of working in the emergency department. Some of their experiences included concerns about the safe management of medicines. Concerns included delays in administering pain relief and medicines to patients because of lack of staff, short supply of medicines in the department and medicine errors occurring in the non-designated care areas in the corridor.

Patients accommodated in non-designated care areas, such as the corridor experienced delays to the administration of pain-relieving medicines. We observed health care support workers had to take time to find registered nurses who were available to administer medicines. This meant patients did not receive pain relief in a timely manner.

The ED had a deteriorating compliance rate for medicines management. Quarterly medicine management reports for July 2023 and October 2023 showed a continuing deterioration with compliance rates across all areas of the emergency department. The major's area had deteriorated from 93.1% compliance in April 2023 to 78.6% compliance in October 2023. The resuscitation area had deteriorated from 93.1% compliance in April 2023 to 78.6% compliance in October 2023. Area 3 had deteriorated from 93.1% compliance in April 2023 to 78.6% compliance in October 2023. The ED had deteriorated from 93.1% compliance in April 2023 to 78.6% compliance in October 2023. There was a lack of up-to-date patient group directions (PGDs) for staff to follow. These are written instructions to help specific members of staff supply or administer medicines to patients, usually in planned circumstances. The Trust provided 11 PGDs that were in use in the emergency department. Out of the 11 PGDs, 6 were past their expiry date. This increased the risk of staff administering medicines outside of the legal framework. The trust had a medicines management policy, which staff working in the emergency department were required to follow. However, this policy had a review date of December 2023 and there was no documented evidence the policy had been reviewed. This meant it could not be as assured the policy still met the current needs of the service and fully reflected national guidance.