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A hospital trust has admitted it may have to improve quicker than expected after health inspectors raised concerns about slow progress.
Medway Maritime Hospital was inspected by the Care Quality Commission (CQC) in December and January and in its report published today has been told it still requires improvement.
The inspection, which was held almost six months ago, gives the hospital the same rating as its last inspection in 2018 and came before the Covid-19 crisis putting additional pressure on services.
But two departments at the centre of the hospital's response to the coronavirus pandemic have received high praise from inspectors.
Critical care is now rated "outstanding" and the end of life care being upgraded to "good" after the care watchdog visited last year.
But inspectors say there are still some serious issues which need ironing out at the hospital in Gillingham, which cares for almost 425,000 patients in Medway and Swale.
While some departments were given better ratings, leadership was downgraded to inadequate as was the medical care for older patients.
Medway NHS Foundation Trust chief executive James Devine told KentOnline he accepted the "fair and balanced report" and what inspectors said needed to be addressed.
"We can sometimes forget when the CQC comes in December and January, it's a very busy time and you're at your most pressured," he said.
"The fact we were able to evidence the improvements, not withstanding some areas we still need to make, is a positive thing.
"The team only comes in for a few days and it's difficult to capture everything the hospital wants to tell them since the last inspection 15 months prior.
"The route to getting to a better rating in future remains unchanged.
"We know where to focus and we recognise much of the positive things in the report.
"But those areas we see less positive reviews, we've got to make a step change and perhaps expedite those improvements."
Mr Devine said a new "dedicated director" to oversee infection prevention control had been appointed to target medical improvements.
He added financial management remains good and the "strength of clinical leadership is central to the improvement plan".
"We pride ourselves in being clinically led – doctors and nurses have a key voice and it's important we look to embed that ethos across the hospital," Mr Devine added.
"The important thing is the compassion of carers. Although that's an obvious thing, as inspectors are only there for a couple of days they don't always see that.
"So to see that in the volume they did was really great."
"It's fantastic and a full credit to the leadership team and doctors and nurses that make up the critical care team across the hospital"
One of the stand out areas in the report is the hospital's "outstanding" critical care department and end of life support, which improved to a "good" rating.
Mr Devine said: "It's fantastic and a full credit to the leadership team and doctors and nurses that make up the critical care team across the hospital.
"Areas of critical care and end of life really are at the heart of the type of patients we're seeing at the moment [with Covid]."
The report also highlights how staff cater for individual patients based on their specific needs and preferences.
He praised colleagues from the end of life team for showing high levels of "dignity and compassion" to patients coming to their "final days or hours".
"The fact they can show that over a seven day period is testament to the types of doctors and nurses they are.
"In critical care, it's slightly different type of nurses because they're dealing with someone who's acutely unwell.
"With Covid, they're seeing those patients in greater numbers and the fact they're providing that direct care to patients and families is a real testament to them and their profession."
Medical care criticised
Medical and older person care at the hospital has been pointed out as an area which needs to get better.
But the CQC did not carry out a full review of the department and only looked at "one or two" services, Mr Devine said.
The hospital has been told to improve the consistency of older person care but there were several highlights surrounding the hospital's compassionate care and its acute frailty unit.
Mr Devine said: "The Medway population, in parts, has a higher profile of elderly patients and so we have a frailty unit dedicated for elderly patients – and importantly we can see those patients coming in and going out quicker – wasn't fully captured in the report.
"Nevertheless what we've been told is we've got more to do and that features in the improvement plan.
"It's disappointing medical care went down but six months have passed and we've made immediate improvements to infection control."
Leaders 'not always aware of risks'
The strength of leadership at the hospital has been criticised by the inspectors who said managers were not always aware of "risks, issues and challenges within the services".
The CQC said leaders had not always been "in touch with what was happening on the front line" or understand risks when staff presented them to management.
The report says: "Although the trust had established programmes to positively impact on culture, they had not had time to embed throughout the organisation and historical poor behaviours persisted."
Mr Devine said the trust launched a new plan last July which would look to address the concerns and is confident it will help improve issues raised by the CQC.
"Medway has had historic challenges and changes in leadership. We took the opportunity to review our strategy and objectives in 2019 following the changes.
"We're now almost 12 months on and would hope at our next inspection we'll be further along embedding them and the CQC will be able to see that."
Ward closure 'was our decision'
The Dickens Ward, which inspectors pointed out as having particular issues relating to safe and dignified care for patients, has been closed since the inspection.
The ward, which was used as an overflow ward when A&E was particularly busy and for those requiring extra rehabilitation before discharge, suddenly shut in February amid suggestions inspectors had told trust bosses to act.
Mr Devine denied the trust was told to close it down by the CQC and leaders had already been carrying out "regular reviews" about the future of the ward.
"We were not told to close that ward, it was a decision taken by us.
"You have to take a decision about whether can we provide good strong person centred care in that area.
"We were able quite quickly to give care in the community setting and move patients into a speciality bed and doing that we didn't need to keep that open.
"The CQC highlighted some issues and when we reviewed those took the decision to close that ward and care for patients fit in the community or at home and move a small number of patients to a speciality ward."
Covid crisis 'doesn't change our improvement plan'
Mr Devine said work on improving areas of the hospital identified by the CQC will not be impacted by the response to Covid-19 as it will be guided by an improvement plan which was started before the pandemic hit.
The hospital has continued with carrying out cancer care and some emergency elective surgery.
"Whilst Covid took centre stage, we were continuing that work across the hospital," Mr Devine said.
"The fact we need to enhance the improvements and further embed some we've already made was already going to be part of the plan.
"Covid being with us now, for the next few months and into the summer and winter doesn't really change anything fundamentally in what we need to do."
Bosses are looking to return to "a new normal" with more elective surgery and other plans that had to be put on hold.
Doctors, nurses and all hospital staff will be invited to share their input from the CQC inspection to develop how the improvements will take place.
The document will be published when it is complete, Mr Devine confirmed.
He added: "We've seen good changes in our staff survey which demonstrates culture in the hospital has improved from the last one 12 months prior particularly for morale and engagement."
'Not all bad news', says councillor
Medway Council opposition spokesman for health and deputy leader, Cllr Teresa Murray (Lab), said: "The report is not all bad news and I congratulated the staff for the outstanding rating received for critical care with a good rating for end of life care.
"Both are so important when it comes to dealing with the impact of the Covid-19 crisis and I know that families across Medway will be reassured that their loved ones are in good hands at this frightening time."
But she warned leaders at the hospital they needed to "reflect on their ability to drive improvement", adding: "When Covid restrictions are lifted they will need to refresh practice and fully embed the advances and modernisation that have emerged during the crisis.
"Staff have a right to expect that their leaders are competent, inspiring and supportive but the CQC report shows that this is not always the case."
Labour leader Cllr Vince Maple added the group would continue lobbying for increased funding to the NHS saying improvements required by the CQC will not be possible otherwise.
Rochester and Strood MP Kelly Tolhurst (Con) reacted to the news saying she was pleased with the critical care and end of life ratings.
"I have been working very closely with Medway Maritime Hospital over the past several months to identify what more can be done to improve health services across Medway," she said.
"These two core services are vital in our response to treating coronavirus and this has been reflected in the exceptional way that the hospital has been handling the current crisis and the praise that I have heard for it.
"There is of course more work that needs to be done and I know the trust would have liked to have seen improvements across all areas, but I am also glad that many other improvements have been acknowledged in the report, such as its use of resources.
"The leadership of the trust have always been open and honest about the pressures that face them, and I am pleased with how they are now reacting to these challenges. Changes have already been put in place since the CQC carried out their report at the hospital and I am certain that the hospital is on the path to improvement.
"I am tremendously proud of all the staff at the hospital who are doing a superb job, not only during this difficult period but always, to raise the quality of care and deliver a great service for all of us in Medway."
Read more: All the latest news from Medway
