Medway Maritime Hospital

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed a limited number of quality statements in the well-led key question and found areas of concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. Though the assessment of these areas indicated areas of concern since the last inspection, our rating for the key question remains good. Staff described a poor culture, staff feared reprisal for raising concerns, senior leaders were not focused on patient care and did not listen when staff escalated safety concerns. However, the service had a defined management structure with clear lines of accountability and most staff described a supportive culture at local level.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Fifteen staff contacted us between 31 August 2023 and 4 April 2024 to raise concerns about the culture of the department. Some staff described the culture as toxic because of the behaviours and capability of leaders. Three staff told us about bullying by leaders and 5 said staff were threatened with disciplinary action or targeted for speaking up. Nine, talked about leaders taking no action when staff raised concerns, so nothing changed. Staff described ‘mean’ interactions from some leaders. These included halting conversations by saying “conversation closed” and “discussion over” and telling staff they were “dropping the ball” and “should work harder.” Some staff raised concerns about the competency of some leaders. They wondered whether the poor behaviours exhibited were because they lacked the competencies or skills to conduct their role. One member of staff stated that a manager had made clinical decisions when this was not their role. During the on-site assessment some staff told us that when they escalated concerns about staffing and overcrowding to immediate leaders, their comments were ignored and not taken seriously. One member of staff felt the organisation put performance, targets and finance above patients and care. A second felt senior managers at care group, divisional and executive level did not listen to safety concerns. A third member of staff commented that senior managers did not acknowledge the risks held by the emergency department. They described a culture where Band 7 nurses lived in fear of punishment from senior leaders. The staff survey reported that only 48% of ED staff felt safe to speak up about anything that concerned them and only 35% were confident that the organisation would address any concerns raised. However, senior leaders told us the trust offered staff ways to raise concerns anonymously or to more senior leaders or via listening sessions where actions were taken to improve the culture and environment for staff.

There was a management structure with clear lines of accountability. The urgent and emergency care service was part of the emergency and acute care group, led by a clinical director, head of nursing and general manager. The care group was part of the medicine and emergency care division. The leaders of the care group were accountable to the leaders, medical director, director of nursing and director of operations, of the medicine and emergency care division. The clinical director of ED and 2 matrons were responsible for day-to-day operations and were accountable to the emergency and acute care group leaders. The trust had a development programme for all levels of leadership and provided a management essentials training course for managers to complete. There was a structure of governance meetings, where the leaders reviewed various performance indicators, which included ED performance against trust and national targets, complaints, incidents, risks, and staffing. However, meetings could not always take place due to operational pressures.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Governance, management and sustainability during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Patients did not express any comments about how the service worked with local communities.

Leaders described how they worked with system partners and considered the needs of their local population to support improvements to patient experience.

System partners described how the trust including leaders for the ED, worked collaboratively with them to improve patient experience, this included patient experience in the emergency department.

There was a shared agreement with the system partners about the processes that supported system wide collaborative working.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.