Clifton Dialysis Unit

Clifton Dialysis Unit is operated by Fresenius Medical Care Renal Service Limited. It has been operating since September 2005. Patients attending the unit are referred to the local specialist renal and dialysis commissioning trust. The unit, located in the grounds of Blackpool Teaching Hospitals NHS Foundation Trust, functions as a satellite unit and treats patients in the Blackpool, Fylde and Wyre areas.

The unit is a nurse led unit, comprising of a manager, deputy manager, two team leaders (all registered nurses), five other registered nurses, and eight dialysis assistants. The unit has 20 haemodialysis stations, two of which are located in side rooms, and provides three treatment sessions per station per day. It is located in a purpose built unit in the grounds of the local NHS hospital (the host trust). Facilities include a patient waiting area with a disabled access toilet, a patient treatment and weighing area, a range of offices, clean utility, waste utility, staff changing rooms and kitchen, storeroom, technician’s rooms and a water treatment plant.

The unit provides haemodialysis treatment to adults aged 18 years and over, who have non-complex needs. Currently the unit provides treatment to 38 patients between the ages of 18 and 65 (6292 sessions between March 2016 and February 2017) and to 55 patients aged over 65 years (8328 sessions in the same period). The unit did not have any patients who were receiving home treatment.

We inspected this unit using our comprehensive inspection methodology. We carried out the announced part of the inspection on 26 June 2017, along with an unannounced visit to the unit on 5 July 2017.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate. Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we do not rate

We regulate dialysis services but we do not currently have a legal duty to rate them. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary. We found the following areas of good practice:

• There were reliable systems and processes in place to keep patients safe, including staff training, incident reporting, hygiene and infection prevention and control measures.

• The unit’s layout and staff use of equipment, including prompt response to machine alarms, kept people safe. Medicines were stored, prescribed and reviewed in line with provider’s medicines management policy.

• Patients were assessed for suitability for treatment to ensure the unit was able to accommodate their care needs. The multidisciplinary team reviewed individual treatment prescriptions monthly, and patients' vascular access sites were regularly monitored.

• Dietitians provided advice monthly to each patient, and there was access to psychological and social work support if needed.

• Staff rarely cared for patients living with dementia or learning disabilities. Staff were trained in and aware of the principles of the Mental Capacity Act and the Deprivation of Liberty Safeguards.

• Appointment slots were allocated to patients taking into account their individual needs. Staff supported patients to go on holiday through co-ordinating care at other clinics in the UK, Europe and other countries.

• Care and treatment was evidence based in line with appropriate guidance. Staff were competent to provide the right care and treatment, and competencies were regularly reviewed. New staff were supported through an induction and mentoring programme.

• There were no written complaints in the reporting period; but there was evidence of shared learning from complaints and incidents that occurred in the provider’s other clinics.

• A named nurse for each patient helped to ensure continuity of care. The annual patient survey reflected improvements in the key areas such as staff treating patients with dignity and providing opportunities to discuss their care, and in patients' views that the unit had a happy friendly atmosphere.

• Staff supported families who were bereaved and ensured attendance at patient funerals.

• A clear management and reporting structure was in place. The clinic manager and deputy manager had the appropriate skills, knowledge, and experience to lead and engage effectively with their staff and patients.

• The unit’s clinical governance strategy supported the provider’s strategic aims; effectiveness against this was monitored through a full range of clinical and governance benchmarking audits.

However, we also found the following issues that the service provider needs to improve:

• Staff did not always check patients’ identification prior to connecting patients to the dialysis machines or prior to administering additional medicines.

• Mandatory training completion rates were low for some topics including data security awareness and duty of candour training

• Records of what cleaning had been undertaken were not made, which meant staff could not provide assurance that daily cleaning took place in all of the necessary areas.

• There was no policy or procedure on the identification and management of potential sepsis in a deteriorating patient and staff did not use a nationally recognised early warning score tool.

• We found repeated issues identified following audits over several months. We were concerned that actions following these results were not bringing about the required improvements.

• The resuscitation trolley was not sealed, which meant there was a risk that staff would not be aware of any unauthorised access to the equipment stored in the trolley, including anaphylaxis medicines.

• Documentation to record checks of resuscitation equipment did not include the automatic defibrillator battery.

• Discussions between staff and patients were not always held in private, which meant there was a risk other patients would overhear confidential information.

• Patients' records did not always contain the necessary information including evidence of consent, evacuation plans, prescriber signatures and patients' details on each page. Additionally, patients' records were stored in unlocked cabinets in the main patient treatment area which, although inaccessible to the general public, still posed a risk of unauthorised access.

• Managers had no formal process for monitoring or recording compliments received. In addition to this, staff recorded informal complaints in individual patients' records rather than somewhere central, which made it more difficult to monitor trends over time.

• The unit did not monitor compliance with the requirements of the NHS workforce race equality standards.

• The unit’s risk register was not yet fully embedded and information such as who is responsible for managing each individual risk was missing.

Following this inspection, we told the provider that it should make improvements to help the service improve. We also issued three requirement notices. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals North