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Medway Maritime Hospital has been told to take urgent action to deliver improvements for its patients or risk changes being imposed on its leadership.
Health regulator Monitor has told Medway NHS Foundation Trust, which runs the Gillingham hospital, to set out a "credible" plan to transform the services it provides.
Monitor is increasing its regulatory action after discovering the problems at the trust are broader than those uncovered by NHS medical director Sir Bruce Keogh, which caused it to be put into special measures.
The review, which investigated high death rates at Medway, branded the A&E layout "totally unsuitable" and said it must be upgraded.
Last month, the Care Quality Commission also ordered urgent improvements to be made to it its maternity services amid "serious concerns" about treatment.
"We know that staff are working hard to improve the quality of the trust's services, but we need the organisation's leadership to do more to make sure that urgent change happens quickly..." - Monitor's Paul Streat
Following the Keogh review, Jonathan Guppy was appointed improvement director to support the trust in fixing its problems.
He has found that while the trust is focused on tackling specific quality of care issues, it needs a credible clinical strategy for the organisation as a whole.
Monitor said it was also concerned the trust's failure to properly address poor A&E performance - and problems in its maternity services - mean it continues to operate in breach of its licence.
The regulator has told the trust to take further action, including preparing and implementing the necessary clinical strategy. It has also imposed a new condition on the trust's licence to ensure the trust has the appropriate leadership to deliver the necessary improvements.
Paul Streat, regional director at Monitor, said: "We know that staff are working hard to improve the quality of the trust's services, but we need the organisation's leadership to do more to make sure that urgent change happens quickly.
"The new licence condition gives us the power to make changes at the top if the current leadership fails to deliver."
A spokesman for the NHS Trust said: “The Trust recognises the importance and urgency of the issues set out by Monitor and is working closely with the regulator and partner organisations to address these in full. In addition to the issues being addressed following the Keogh review earlier this year, the Trust completely acknowledges the need for a new and comprehensive clinical strategy.
“Trust staff met with NHS England and other organisations last week to review progress on the action plan arising from the Keogh review and were able to point to a series of positive initiatives and quality improvements that will help improve patient care.”
Since the report, more than 60 additional nurses have been employed and over clinical consultant appointments have been made. It has also started work on the redesign of A&E to improve patient experience and patient flow.
Trust Chief Executive, Mark Devlin, added: “Our new leadership team has made some real and tangible progress in tackling issues raised by the Keogh review and I want to commend staff on their work to date and promising areas of progress. However, I absolutely accept the need for a new comprehensive clinical strategy to sustainably transform services. Ensuring delivery of the improvements we have already in progress and shaping the new clinical strategy are the top priorities of our new Medical Director, Chief Nurse and the whole team.”
