Three struggling acute trusts placed in regulatory special measures a year ago have failed to make significant progress and should remain in special measures, the chief inspector of hospitals has recommended.

Concerns over safe staffing levels, leadership and patient flow are highlighted as issues at all three of the organisations in Care Quality Commission inspection reports published this week. They were Medway Foundation Trust, North Cumbria University Hospitals Trust and United Lincolnshire Hospitals Trust.

Medway Foundation Trust was given an “inadequate” rating overall with chief inspector Sir Mike Richards describing its leadership as the “most unstable” the regulator had come across since it overhauled its inspection regime last autumn.

North Cumbria University Hospitals Trust and United Lincolnshire Hospitals Trust were both rated “requires improvement”.

A fourth trust placed into special measures following the Keogh review in summer last year, East Lancashire Hospitals Trust, was also rated “requires improvement” by the CQC this week, but is to be released from special measures.

Sir Mike said in a statement the trust has made “real progress” since the Keogh review “with the way that it is led changing significantly”.

He added: “Special measures are designed to provide intensive support to struggling trusts and East Lancashire Hospitals Trust has clearly gained from this support.

Medway Maritime hospital

Medway Foundation Trust was given an “inadequate” rating overall by the CQC

“There is no doubt that the trust is heading in the right direction and will continue to benefit from the ongoing support from the NHS Trust Development Authority as they come out of special measures. We will return in time to check that the improvements we have identified on this inspection have been made.”

Services at all four trusts were rated “good” under the CQC’s “caring” rating heading. However, inspectors flagged problems with estates, processes and governance which prevented the care they provided from being effective or safe.

East Lancashire is the third of the 11 Keogh trusts placed in special measures last year to come out of the regime. It follows Buckinghamshire Healthcare Trust and Basildon and Thurrock University Hospitals Foundation Trust, which were released last month.

The CQC has completed follow up inspections at all 11, and reports into the remaining five are expected in the next week.

How the four trusts were rated

 SafeEffectiveCaringResponsiveWell ledStill in Special Measures?
East Lancashire Hospitals TrustRIGoodGoodRIRIN
Medway FTInadequateInadequateGoodRIInadequateY
North Cumbria University Hospitals TrustRIRIGoodRIRIY
United Lincolnshire Hospitals TrustRIRIGoodRIRIY

RI = “requires improvement”

Medway Foundation Trust

“Unstable” and “inconsistent” leadership and a lack of progress in improving quality of accident and emergency services were particular areas of concern at Medway Foundation Trust.

Inspectors found pressure on the department from high levels of attendances combined with poor escalation processes led to patients being “queued in corridors” and occasionally spending the night in a mobile overflow unit intended only to be used during the day.

The report highlighted the fact that the executive lead for A&E was not aware of this as an example the gap between the board and the front line.

The trust has not met the four hour accident and emergency target since 2012 and was heavily criticised by the Keogh review team for poor care in the department when they visited in May 2013. However, CQC inspectors reported they were “unable to identify a strategy to manage the patient flow issues”.

Critical care services and children and young people’s services at the trust were rated good.

Chief nurse Steve Hams told HSJ the CQC report was a “fair assessment” of the trust’s progress but pointed out there had been improvements in a number of areas, despite the inadequate rating.

Medway is also in an extremely challenging financial position. Its original financial plan for 2014-15 forecast a £29m deficit, equivalent to 12 per cent of turnover. The board is due to submit a revised plan to the regulator by the end of the month.

The board were in the process of appointing a shadow contingency planning team to produce a plan for the trust’s future viability earlier this year. However, this has now been put on hold while the trust works with University Hospitals Birmingham Foundation Trust to improve its operational effectiveness.

Mr Hams said: “The board have decided to get the first phase of the UHB diagnostic through and then make a decision at that point about which way we are going next.”

North Cumbria Trust

CQC inspectors found a lack of effective, honest and open communication from middle and senior management remained an issue at North Cumbria Trust.

They noted staff gave a mixed picture regarding the trust culture but a number said they were fearful about raising concerns. Some individuals became “visibly upset” when sharing their concerns with inspectors and worried their names would be shared with managers, the report said.

Recruitment was also a significant challenge for the trust, which the CQC report noted was made more difficult by the trust’s remote geography. It noted the trust had a particularly acute shortage of doctors and in some cases was unable to open beds due to a lack of staff.

Critical care services at both of the trust main acute sites were rated good as was end of life care at West Cumberland Hospital and the maternity service at Penrith Community Hospital.

Chief executive Ann Farrar said: “What is clear from the CQC report is that some improvements, such as those relating to medical records and outpatients, are within the gift of the Trust to deliver. 

“Other problems, such as those linked to recruitment, will require NHS system wide solutions to ensure we can sustain services at West Cumberland Hospital and this must be addressed in the development of our five years strategies with NHS Cumbria Clinical Commissioning Group.”

United Lincolnshire Hospitals Trust

A lack of engagement by senior medical staff was found to be a continuing problem at United Lincolnshire Hospitals Trust along with poor record keeping and chronic staffing shortages in some areas.

Inspectors noted an improvement in nursing leadership throughout the trust and also praised the practice of involving patients and relatives who had made complaints in the recruitment of new staff.

However, they said several consultants had complained their concerns were not listened to by senior management.

The inspectors praised the largely new executive team for their vision and their practice of working across all three of the trust’s main acute site. However, despite this they reported staff had a “them and us” attitude and did not connect with the trust identity, preventing the timely spread of best practice across all the sites.

Trust chief executive Jane Lewington said the organisation was “disappointed” not to come out of special measures but acknowledged the trust was still on a “quality improvement journey”.

“The CQC reports shows we have a majority of ‘good’ ratings – 63 compared to 45 ‘requires improvement’. I am also delighted and proud that the CQC recognised just how caring our staff are in everything they do. This is a marked improvement from the Keogh Review and CQC inspections last year.”

East Lancashire Hospitals Trust

CQC found “much evidence” the culture of East Lancashire Hospitals Trust “was now positive, open and honest”, when they visited in May.

The report said the “vast majority of staff spoke of the improvement they experienced in the culture in the organisation” and “spoke highly of the executive team”.

However, the report said the fact the chief executive and medical director were interims and the chair had only recently been appointed meant the trust leadership had been rated as requires improvement.

The report said the trust needed to continue to focus on ensuring sufficient staffing levels, continuing the improvement in the management of complaints and improvement of risk management.

Interim chief executive Jim Birell said: “I am delighted at the outcome and very pleased for our hard working and dedicated 7000+ staff, who were devastated by the findings and criticisms of Keogh. 

“We can now draw a line in the sand and look to move forward with the quality and clinical strategies that will enable us to provide the best possible safe, personal and effective care for our patients.”