Significant improvements need to be made immediately at a hospital emergency department after the healthcare watchdog found a range of failings.

The A&E and urgent care department at Medway Maritime Hospital has seen its rating fall to the lowest level following a surprise inspection before Christmas.

Medway Maritime has been given a damning report

Inspectors from the Care Quality Commission (CQC) told hospital bosses they need to address eight main issues to improve patient safety in a report published today.

Medway NHS Trust chief executive James Devine said improvement steps have already started taking place including increasing capacity to improve flow through the department.

Records were not maintained enough and care for those at risk of deteriorating were placed at further risk. Infection control measures were also highlighted as increasing the risk of cross-infection – including Covid-19 measures – and there were also issues raised about appropriate staffing levels.

The hospital was last visited by inspectors in December 2019 and the emergency department service was rated as requiring improvement.

But this has now been downgraded after three out of five areas – being safe, responsive to people’s needs and well led – were found to be "inadequate".

The department was rated good for being effective and caring for patients.

The visit took place after the CQC grew increasingly concerned about the hospital's "poor performance" against national targets after reviewing data and receiving reports from patients, staff and the other healthcare providers.

A warning notice was issued earlier this month after inspectors raised concerns about long waiting times for patients being handed over from ambulances.

The following day, Mr Devine told a meeting of the trust's board there had been occasions when patients in ambulances were waiting eight hours to be transferred into the hospital.

Mr Devine said this had reduced to an average of two hours 14 minutes by mid-January and has since fallen to an average of 40 minutes.

CQC inspectors found patients were not being monitored effectively and this posed a risk to those whose condition was at greater risk of deteriorating.

Dr Julian Spinks is a GP in Medway

The report found patients were not receiving timely clinical care when needed and records were incomplete or not updated in timely fashion.

CQC deputy chief inspector of hospitals for London and the South, Nigel Acheson, said: “We saw that staff were working hard to provide care to patients in very challenging conditions.

“Given the pressure the trust was under, the decision to inspect during this period was a difficult one.

"However, we had significant concerns from reviewing our own data, the views of healthcare system partners and information shared by people who worked for and used the service.

"We had a duty to inspect to support the trust and identify where improvements needed to be made.

“After the inspection we told the trust leadership of our concerns and issued a warning notice to ensure the necessary improvements not only took place but were embedded.

'Given the pressure the trust was under, the decision to inspect during this period was a difficult one...'

“Since the inspection, the trust has developed a detailed improvement plan. We will continue to monitor the service and will not hesitate to take further action if required, in accordance with our legal powers.”

Inspectors say they found records were also not regularly maintained for nursing care, falls and skin risk assessments.

Patients also experienced "substantial delays" before being admitted or discharged creating a "poor flow out of the department" into the wards or being sent home.

Covid-19 infection prevention measures were found to struggle to separate "traffic" through the departments leading to issues for "adequate social distancing" due to narrow corridors.

The team also found a "hot zone" toilet in a "cold zone" within the department, which they said increased the risk of cross-contamination for patients or staff.

At the time of the inspection, Covid testing took up to four hours to return results which the CQC also found increased possible contamination risks.

But inspectors praised staff for ensuring separate zones were established and their understanding for infection prevention measures and general cleanliness of the department.

Responding to the report, Mr Devine, who previously reflected on a year of sustained pressure, said: "We have taken a number of steps since the CQC’s visit to address the findings from their inspection, including taking immediate action to improve the way we manage pressures within our emergency department.

"We have implemented an improvement plan to ensure we are consistently providing safe, high quality patient care, which is already making a positive difference to patients’ care.

"Actions we have put in place include working with health partners to reduce the number of patients waiting in ambulances, introducing processes to quickly identify and prioritise patients who deteriorate in ambulances, and opening more beds so that patients don’t wait so long to be admitted."

The hospital has also opened 20 more beds to cope with demands, increased reviews of patients waiting to be admitted leading to reduced waiting times, processes to quickly identify patients whose conditions are deteriorating.

A cross-agency approach to improve timely discharge for patients not needing to stay in hospital has also been introduced and a tailored development programme to improve leadership is now in place, the trust said.

Cath Campbell is head of hospital inspection in the south east

Staff told inspectors they felt supported when they need extra help to carry out deep cleans of areas changing from Covid hot zones to cold zones and there was sufficient levels of personal protective equipment and hand sanitiser.

The report highlighted the department did not have enough nursing and support staff or medical staff with the correct qualifications and experience to carry out the right care and treatment for patients.

Leadership, governance and the overall culture of the department did not always provide the best levels of support to provide "high quality person-centred care", inspectors found.

The CQC pointed out five areas the trust must improve:

• ensuring patients are effectively monitored for deterioration and receive timely support
• ensuring timely access to urgent and emergency care through improvements in the flow in and out of the department
• ensuring risks are adequately assessed and maintain good governance in the department to protect patients from potential harm
• keep up to date records for providing care and treatment reflecting each patient's treatment pathway
• employ enough staff with the right qualifications and skills to keep patients safe from avoidable harm

A further three areas the hospital should improve were highlighted including working to improve Covid-19 testing and waiting times for results, reviewing the environment to segregate routes within the department to reduce cross contamination and working with external mental health partners to improve waiting times for crisis beds and onward travel arrangements.

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