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A Kent hospital trust that is already in special measures has been told to improve after inspectors found "blood spatters'', people waiting on trolleys for hours and A&E staff saying they were "under siege''.
The Care Quality Commission (CQC) issued a formal warning to Medway NHS Foundation Trust after an unannounced A&E inspection in December in response to "anonymous concerns'' raised directly with the regulator.
During the inspection, CQC chiefs found a "crisis situation'', with blood-stained walls, serious overcrowding, problems with ambulances queuing outside, not enough staff and unsafe practices which could be life-threatening.
The problems at the Medway Maritime Hospital in Gillingham come after the troubled trust was forced by the health regulator Monitor last month to appoint a new interim chief executive and chairman.
A major report in December from health firm Dr Foster said the trust had significantly higher than expected death rates while in October the CQC issued three formal warnings over poor maternity care.
During the maternity inspection, experts found an ``almost constant demand for extra midwives to staff the delivery suite'', a lack of equipment for monitoring blood pressure in women who had undergone caesareans and problems with emergency equipment.
In the latest CQC review, inspectors said they could not judge the A&E care at the Medway Maritime Hospital to be safe.
They said patients arriving by ambulance were the worst hit, with not enough cubicles and trolley bays in A&E to provide assessment.
Instead, a mobile unit had been set up outside the hospital and was being used as an "overflow area'' where patients brought in by ambulance could be assessed.
Despite the fact patients should only stay there for 30 minutes, many were staying longer due to there being no bays or beds in the main unit and a lack of staff.
In the main unit, inspectors found patients waiting for hours on trolleys. Patients were also not near resuscitation or other vital equipment.
The report said: "On our arrival in the department there were 20 patients who had been in there for more than four hours, waiting to be seen by doctors. Seven of these had been in the unit for over 11 hours and one patient had been there in excess of 19 hours.
"Staff and a person's relative reported that during the preceding night there had been up to 17 people on trolleys in the corridors waiting to be seen and 16 ambulances waiting for spaces to bring in more patients.
"A staff member said that there had not been a free cubicle for five consecutive days.''
One patient who was cold had asked for a blanket at 4am but had still not been given one at 8am.
Another patient "had not been offered any food or drink for 18 hours, although this person had no medical reason to prevent or restrict them from eating or drinking.''
One patient who wanted pain relief had not been given any while one elderly person had been on a trolley for over 20 hours. Other patients were left in cold rooms with only short-sleeved nightwear.
Inspectors also looked at cleanliness and saw "cubicles with visibly dirty radiators and paintwork, stained floors and dirty wash hand basins; and blood spatters on a wall in the (mobile) unit.
"The resuscitation area was cluttered with boxes and equipment on the floors including sharps bins. Single use resuscitation equipment was open and not covered or protected from cross contamination.''
Inspectors said records showed cubicles had not been cleaned for several days or weeks before the inspection, which was carried out on New Year's Eve.
Furthermore, many curtains between cubicles were "visibly stained or dirty''. There were also problems with men and women being treated together, which breached their right to privacy and dignity.
The inspectors said the emergency department was "effectively in a crisis situation''.
"More than one member of staff described the situation as 'under siege', and another said, 'I personally don't think we are being supported; it's a constant battle'.
"A relative stated 'The staff have been nice; they couldn't work any quicker' and we saw that medical and nursing staff were working very hard to try and treat people appropriately.
"However, there were too many patients for the capacity of the department, and too few staff to meet their needs.''
Even when inspectors told nurses an older person was at risk of pressure sores, nothing was done to move them to a bed until 22 hours after arrival.
The report went on: "We found that there were times when seriously-ill patients were left unattended. The resuscitation area had an allocation of two nurses at all times.''
However, nurses said this did not happen in practice and admitted there were sometimes no nurses present. There was also a lack of doctors on duty and emergency suction equipment was not assembled.
Inspectors said: "We assessed that care and treatment in the emergency department could not be considered as safe.
"Staff told us that moving people to the wards was difficult. One member of staff told us that staff on the wards had 'No concept of what it's like down here... they don't understand what it's like to have 12 ambulances stacking outside'.''
Adrian Hughes, regional director of CQC in the South, sad the trust was taking steps to improve its services but there were too many patients for the capacity of the department.
"It is clear that the work taking place to make improvements has not yet translated to better patient care in the emergency department.
"We have referred our findings here to local commissioners, Monitor and NHS England.''