Medway Maritime Hospital

Updated 28 April 2023

Pages 1 and 3 of this report relate to the hospital and the ratings of that location, from page 4 the ratings and information relate to maternity services.

We inspected the maternity service at Medway Maritime Hospital, managed by Medway NHS Foundation Trust, as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

Our rating of this hospital is requires improvement overall.

Our rating of the Maternity service is good. We rated safe as good and well-led as good for maternity.

How we carried out the inspection

We visited the hospital and spent time in all of the maternity areas. There was a Maternity Care unit (MCU), fetal medicine and antenatal clinic area. We also went to The Birth Place, which was the midwifery-led unit. Whilst visiting the delivery suite, we also visited obstetric triage, obstetric theatres and Maternity Enhanced Care Unit (MECU) which was a four-bedded bay offering support to women and birthing people who may need additional care. We visited Pearl Ward which was a ward for antenatal care and contained eight transitional care beds. Induction of labour were also managed from Pearl Ward. Kent Ward was for postnatal care and elective caesarean sections were managed from here.

Following our arrival at the hospital, we observed the morning handovers between midwives and medical handovers.

We spoke with 8 pregnant women or mothers whilst we were on site. We also ran a poster campaign during our inspection to encourage pregnant women, birthing people and those who had given birth who had used the service to give us feedback regarding care. We analysed the results to identify themes and trends.

We also spoke with 26 members of staff, including service leaders, all grades of midwives, including some specialist midwives, obstetric staff, the director of midwifery, the head of midwifery, the general manager, the non-executive director safety board champion and the chair for the maternity voices partnership.

We reviewed performance information about this service before and after our inspection. We reviewed 7 sets of maternity records plus eight prescription charts. We also looked at a wide range of documents including standard operating procedures, meeting minutes, risk assessments, incidents and audit results.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/whatwe-do/how-we-do-our-job/what-we-do-inspection.

Updated 30 July 2021

Updated 30 July 2021

Updated 30 April 2020

Our rating of this service improved. We rated it as outstanding because:

• The service had made significant improvements to the findings from the last inspection in areas such as nursing and medical staffing, pharmacy support and nursing patients in recovery area. Nursing staff cover now met national guidance, there was no agency nursing staff use and minimal nursing of patients in recovery beds. The service had also taken steps to address the medical cover shortage gaps.
• There was now an embedded positive culture to making sure leaders and staff provided high-quality care. Staff understood the senior leadership structure and said the team were always accessible and visible. They felt there was now stability at middle management level. This had improved from what we found in the last inspection.
• Medical and nursing staff compliance to mandatory training had improved and showed better compliance than the trust target and was better than at the last inspection.
• The service leadership was compassionate, inclusive and effective. Leaders at all levels demonstrated the high levels of experience, capacity and capability needed to deliver excellent and sustainable care. Leaders had the skills, knowledge and experience to perform their roles.
• Leaders and staff had a clear understanding of issues, challenges, priorities and vision for their service. The service places patients’ safety and individual needs at the core of its strategy.
• There was strong and collective collaboration, team work and support across all functions and a shared focus on improving the quality, safety and sustainability of care.
• Staff were proud of the service as a place to work and spoke highly of the culture. Staff at all levels were actively encouraged to speak up and raise concerns.
• There was a strong visible person-centred culture to providing care across the service. Staff always treated patients with dignity and respect. Staff were highly motivated, passionate and dedicated to make sure patients received the best individualised patient-centred care.
• Staff understood the impact that a person’s care, treatment or condition had on their wellbeing and on those close to them, both emotionally and socially. Staff saw people's emotional and social needs were equally important as their physical needs.
• Staff involved patients and those close to them in making decisions about their care and treatment.
• All staff actively engaged in activities to monitor and improve quality of care. Leaders and staff proactively pursued opportunities to participate in benchmarking and peer review are proactively pursued, including participation in approved accreditation schemes and research.
• The continual development of staff skills, competence and knowledge was recognised as integral to providing high-quality care. Managers proactively supported and encouraged staff to acquire new skills, use their transferable skills and share best practice. Managers made sure staff received specialist training for their role.
• Staff worked collaboratively and found innovative and efficient ways to deliver more joined-up care to people who use services.
• The service was inclusive and took account of patients’ individual needs and preferences. There was a proactive approach to understand the needs and preferences of different groups of people and to deliver care in a way that meets these needs, which was accessible and promoted equality. This included people with protected characteristics under the Equality Act, people who may be approaching the end of their life, and people who were in vulnerable circumstances or who have complex needs.
• Governance arrangements were proactively reviewed and reflected best practice. The service took a systematic approach to work with other organisations to improve quality of care.
• The service managed patient safety incidents well. Staff recognised incidents and near misses and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
• Openness, honesty and transparency were the norm.
• The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix.
• Staff understood their responsibilities and knew the steps to take to protect patients from abuse. They had training to recognise and report abuse and knew how to apply it.

However:

• The high dependency unit did not meet the minimum bed space dimensions as recommended in national guidance.
• Staff did not always keep control of substances hazardous to health (COSHH) secure.
• Patient flow throughout the hospital resulted in delayed discharges and very high occupancy rates. This continued to have a significant impact on discharges from the medical and surgical high dependency units. This delay in discharge also contributed to the majority of mixed sex accommodation breaches the trust reported.
• Out of hours critical care discharges to ward between 10pm and 7am remained a challenge and were worse than the national average. The service relied on the availability of ward beds throughout the hospital and its performance was similar to the last inspection.

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.

However,

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.

However;

• 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 30 April 2020

Our rating of this service improved. We rated it as good because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well.
• The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines in line with best practice. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment and gave patients enough to eat and drink. Managers monitored the effectiveness of the service and made sure staff were competent.
• Staff consistently monitored and managed patient’s pain to ensure they remained as comfortable as possible
• Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Patients and relatives said staff go above and beyond and the care received exceeded their expectations. Staff truly respected and valued patients as individuals. They treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. They were clear about their roles and accountabilities.
• Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• The service did not have a specialist palliative care consultant.
• The service did not consistently have capacity to deliver end of life care training to staff across the trust.
• The trust did not ensure staff had time to attend end of life care training.
• The service did not keep their risk register fully up to date when they reviewed risks.

Updated 28 April 2023

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.

However:

• 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.

Updated 30 April 2020

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

• While the service improved in some areas since the last inspection, it stayed the same or became worse in others.
• While staff had training in key skills, the service did not always ensure everyone completed them.
• The service did not control infection risk well and staff did not consistently follow infection prevention and control policies. The design, maintenance and use of facilities, premises and equipment did not always keep people safe. Records were not always stored securely.
• While the service had improved staff recruitment, there remained significant challenges within theatres. This caused high reliance on bank and agency staff. This issue was identified at the last inspection and continued to require improvement.
• Staff collected safety information but did not display it for patients and visitors to see.
• Not all staff felt respected, supported and valued and staff morale was low in theatres.
• The service did not ensure patients must ensure that all reasonable steps were being taken to improve the quality of service, specifically in relation to access to treatment and waiting times.
• The service did not ensure products deemed as hazardous to health were stored securely.
• The trust was not meeting the Department of Health and Social Care’s standard on eliminating mixed sex accommodation in the recovery area of theatres.
• Patients were still spending longer than they needed to in recovery awaiting placement in the hospital. Patients staying in recovery for an extended time or overnight had their privacy and dignity compromised.
• The leadership, governance and culture did not always support the delivery of high-quality person-centred care.
• In main theatres staff had not been engaged and morale in the department was low and there was frustrations around leadership, low staffing and capacity and flow issues.
• There was a lack of clarity from managers in theatres on whether staffing was maintained in line with national guidelines.
• There was not an effective, structured review and judgement process for mortality and morbidity meetings.
• The trust was still challenged with getting patients who had a fractured neck of femur to theatre within 36 hours of admission. Performance against this was poor.

However:

• Staff understood how to protect patients from abuse, staff assessed risks to patients, acted on these and kept good care records. They managed medicines well.
• Staff gave patients enough to eat and drink and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent.
• Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff delivered compassionate care and treated patients and their loved ones with respect and dignity. They provided emotional support to patients, families and carers.
• The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.
• Staff were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities.

Updated 24 June 2022