Clifton Dialysis Unit

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This is the first time we have rated this service. We rated safe as good. The service had enough staff to care for people and keep them safe. Managers carried out recruitment checks and made sure staff were competent in their roles. Staff had training in key skills, understood how to protect people from abuse and managed infection risks well. Premises, facilities and equipment were clean and well-maintained. Staff managed medicines well. They assessed risks to people and acted on them. Staff collaborated with partners to maintain safe systems. The service managed safety incidents well and learned lessons from them.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People who use the service told us they felt safe and did not have any concerns around safety incidents. People knew how to raise any concerns with staff and with the managers and felt confident their concerns would be listened to and addressed.

Staff knew what incidents to report and how to report them. Staff told us they were encouraged to raise concerns and could easily access the provider’s incident reporting system. Staff told us any reported incidents were reviewed and discussed at daily huddles and clinic staff meetings so shared learning could take place.

There was a culture of safety and learning. This was based on openness, transparency and learning from events that have either put people and staff at risk of harm, or that had caused them harm. Staff identified, reported and managed reported incidents in line with the provider’s incident reporting policy, using an electronic incident reporting system. Incidents were investigated by senior staff with the appropriate level of training. Incident records were completed appropriately and remedial actions were put in place to aid learning and improvement. Lessons learned from safety incidents resulted in changes that improved care for others. Serious incidents were reported centrally to the corporate provider. Service user deaths were also reviewed and investigated by the commissioning trust with involvement from staff at the service. Staff understood the duty of candour. They were open and transparent, and gave people who use the service and their families a full explanation if and when things went wrong. Staff received feedback following the investigation of incidents. Staff met to discuss the feedback and look at improvements to people’s care during daily safety huddles and routine staff meetings.

People told us they were initially assessed and received treatment at the commissioning trust and chose to transfer to the dialysis unit as it was closer to where they lived. They told us the staff at the unit carried out an admission assessment to determine their needs and preferences. People told us they were regularly seen by the nursing staff at the service as well as the renal consultants and dietitians and that their on-going care and treatment was clearly explained to them. People told us they received good support from staff in relation to kidney transplant discussions or if their treatment needed to be transferred to another location.

Staff told us they discussed each admission referral with the commissioning trust and carried out their own assessment. They told us the views of people who use services, partners and staff were listened to and taken into account. Staff were able to describe how they would accommodate temporary admissions, such as people on holiday or those transferred from another dialysis unit for short term dialysis treatment. Staff understood the service’s inclusion criteria and were able to describe which people were eligible for admission to the dialysis unit. Staff understood how to manage people’s risks during an emergency. They told us they carried out routine observations during treatment and people whose health deteriorated were escalated for medical input and promptly transferred to hospital if they required emergency treatment.

Service partners told us the commissioning trust had clinical oversight of people who used the service and the first dialysis treatment was usually completed at the commissioning NHS trust. The service aimed to dialyse people who use the service within 30 minutes of their home. People assessed as suitable could be transferred to a local dialysis unit closer to their homes. This was dependent on them being stable, with good mobility. People with complex health needs were not eligible for transfer to the dialysis unit. The renal matron and consultant told us people using the service were assessed by the consultants within 2 weeks of their initial transfer from the trust and then reviewed monthly by the consultants and dietitians. Where people developed any complications relating to their dialysis treatment or their health deteriorated, they would be transferred back to the care of the renal department at the commissioning trust or to other local hospitals for non-renal complications or health issues.

Care and support was planned and organised with people, together with partners and communities in ways that ensured continuity of care throughout people’s care journey. Policies and processes were aligned to enable a joined up, collaborative approach between staff at the dialysis unit and the commissioning trust during referrals, admissions and discharge, and where people moved between services. The referral and acceptance for treatment policy defined who was eligible for treatment at the dialysis unit. There was a strong awareness of the risks to people across their care journeys. The approach to identifying and managing these risks was proactive and effective. People’s risks and care needs were assessed minimally on a monthly basis through multi-disciplinary reviews. Staff completed life support and resuscitation training and followed the provider’s haemodialysis emergencies policy for managing people whose health deteriorated or had experienced recognised adverse events relating to their dialysis treatment. Care records showed people whose health deteriorated were promptly escalated for medical review and transferred to hospital by emergency ambulance in a safe and timely manner. A handover of nursing and medical records was completed where a person was transferred to another service or discharged from the unit.

People who use the service told us they had not experienced any instances of abuse or neglect at the service. People told us they knew how to raise any safeguarding concerns. They told us if they had any concerns, they would raise them with the managers or with a social worker.

Staff we spoke with were aware of the provider’s safeguarding policy. They told us they had completed mandatory children and adults safeguarding training. Staff understood how to make a safeguarding referral and who to inform if they had concerns. They knew how to access support from safeguarding leads. The interim clinic manager told us they were responsible for the review, investigation and external referral for any safeguarding concerns that had been raised by staff. Staff told us that learning from any reported safeguarding incidents was shared as part of daily huddles and during routine staff meetings.

The provider’s safeguarding policy instructed staff on how to identify and report any safeguarding concerns, including making referrals internally and to external agencies, such as the local authority safeguarding team. The service had safeguarding leads and senior managers had completed the higher level of safeguarding training for children and adults. All eligible staff had completed level 2 children and adults safeguarding training as well as radicalisation training. The training was in line with current intercollegiate guidance for adults and children. The service had reported 1 safeguarding concern in the past 12 months. Appropriate actions had been taken to protect the vulnerable person, with involvement from local authority safeguarding teams.

People who us the service told us staff regularly discussed any changes to their condition and updated risk assessments and care plans on a regular basis. People told us staff carried out routine observations during their dialysis treatment. They told us the renal consultants and dietitians reviewed their dialysis treatment at least monthly and they were kept up to date about any changes to their care and treatment.

Staff understood how to identify and manage risks. They told us they regularly reviewed risk assessments and discussed any changes with people and their relatives. Staff told us new or emerging safety risks were discussed during daily safety huddles. Staff knew how to identify and manage people with suspected sepsis or those whose health condition deteriorated. Staff were able to describe how they carried out and documented vital observations before, during and after dialysis treatment. They told us they would escalate any deterioration in a person’s condition, including suspected sepsis to the managers and renal consultants so people could receive appropriate treatment or emergency transfer to hospital.

People who use the service received an initial assessment to identify key risks and their needs and preferences. Risk assessments were reviewed and updated at least monthly or sooner if there had been any change to a person’s condition. People’s risks were discussed during daily safety huddles and as part of monthly multidisciplinary reviews involving the consultants and dietitians. Staff did not use a recognised early warning score tool to identify people whose health deteriorated. However, they followed guidance in the haemodialysis emergencies policy and used clinical judgement to determine if escalation was required. The corporate provider had aspirational plans to launch a new early warning score tool during 2024/25. Care records showed staff carried out vital observations before, during and after dialysis treatment. Records showed staff escalated any issues or risks to managers and renal consultants appropriately and promptly. The haemodialysis emergencies policy and suspected sepsis risk pathway included guidance for staff around identifying and managing people with sepsis. The service reported 1 instance in the past 12 months where a person was identified with suspected sepsis and they were appropriately transferred to hospital.

People who use the service told us the dialysis unit was safe, spacious and provided a suitable environment for their care and treatment. They told us they had not experienced any issues relating to equipment and felt the premises and equipment were suitably maintained. People were mostly satisfied with the age, condition and quality of the dialysis equipment. However 1 person felt some of the dialysis machines were dated and needed upgrading. Another person told us the main unit area was often cold but staff would adjust the air conditioning when asked. People told us they were encouraged to bring their own blankets.

Staff told us the premises and equipment were suitable for providing safe care and treatment. They told us there were sufficient stocks of equipment and consumable items and they could easily access them when needed. Staff were able to describe the process for ordering and managing consumables and single use items. They told us they carried out routine monthly stock reconciliation and expiry checks. Staff told us there was a clear process for reporting any faults relating to the equipment or the premises. They told us the maintenance staff promptly addressed any faulty equipment and facilities issues.

The design and layout of the unit promoted accessibility in all areas. The main unit had capacity for 24 service users, with 6 side rooms. The service had sufficient numbers of toilets and change areas for staff and service users, including disabled toilets. All the areas we inspected were well-maintained, free from clutter and suitable for providing safe care and treatment. Access to the main unit was secure with coded entry. There were sufficient space for storage of equipment and consumables. The service had enough suitable equipment to help them to safely care for people. The equipment we saw had up to date electrical safety tests, service and calibration. There were arrangements for the safe handling, storage and disposal of clinical waste, including sharps. Flammable chemicals were risk assessed and safely stored, in line with control of substances hazardous to health (COSHH) guidelines. The unit also had biohazard spillage kits. Emergency resuscitation equipment and medicines were kept securely and log sheets showed these were checked daily.

The maintenance engineer was located on site and was responsible for managing facilities and equipment. Water purification plant checks were carried out daily and weekly and records for May and June 2024 showed these had all passed. Maintenance records showed the water treatment plant, dialysis machines and other equipment were checked daily and their electrical safety tests, calibration and servicing was up to date and in line with the provider’s planned maintenance schedule. The service reported there had not been any incidents relating to equipment during the past 12 months. The service had an emergency preparedness plan for the prevention and management of emergency situations. The service had suitable systems for managing fire safety, including routine testing of fire safety systems and equipment and utilising personal emergency evacuation plans for people who use the service.

People told us there were enough staff in the unit and they provided safe care and treatment. They spoke positively about the way staff communicated and interacted with them and told us staff responded quickly when they requested assistance. People told us they felt staff were suitably trained and competent in their roles and they did not have any concerns around staff competence and abilities when providing care and treatment.

Staff felt the recent recruitment of new staff was a positive improvement. They told us their workload was manageable and they received good support from managers. The new clinic manager told us they had been in post for 2 weeks and were undertaking induction training and shadowing with the interim clinic manager. Staff told us they kept up to date with mandatory training and were supported to complete training. The clinic manager told us they maintained a training matrix and staff were informed when they needed to update their training. Staff (including temporary bank and agency staff) told us they received an induction and underwent competency based trained when they started their role. Staff told us they received annual appraisals with their line managers. Staff were positive about on-the-job learning and development opportunities and told us they were supported well by the managers.

The service had sufficient numbers of nursing and support staff. We saw the nurse to service user ratio was 1:4 with a skill ratio of 60% nursing staff to 40% non-registered clinical staff. There was an appropriate skills mix with at least 3 registered nurses and 3 dialysis assistants minimum on each shift. We observed staff interacting with people who use the service and saw staff were friendly, calm and polite when communicating with them and delivering care and treatment. We saw people calling for staff assistance and they responded promptly.

The service had enough medical, nursing and support staff to keep people safe. Managers could adjust staffing levels daily according to people’s needs. The service was nurse led and employed 16.37 whole time equivalent nursing and support staff. The service did not have any staffing vacancies at the time of our visit. The staff were supported by 2 renal consultants and 2 dietitians. Staffing levels across the service were in line with the British Renal Society multi-disciplinary renal workforce plan guidelines (October 2020). Sickness and leave cover was provided by existing staff and through the use of regular bank staff. Agency staff usage was low. Staff sickness and turnover rates were either similar or better than the average of the provider’s other locations nationally. Staff received and kept up-to-date with their mandatory training. The mandatory training was comprehensive and met the needs of people who use the service and staff. Most staff (93%) had completed mandatory training, in line with the provider’s training completion target of 90%. Staff received a full induction tailored to their role before they started work and underwent annual clinical competency checks and appraisals. The provider’s recruitment policy outlined the recruitment and fit and proper person checks carried out for new staff, including for agency staff. We looked at seven staff recruitment files which showed appropriate recruitment and pre-employment checks had been carried out.

People told us the premises and equipment were visibly clean and tidy and they did not have any concerns relating to the cleanliness of the environment and equipment. People told us staff would place them in isolation rooms if they had any untoward symptoms, such as cold symptoms or if they had returned from holiday. People told us staff used gloves and aprons when providing care and treatment. They told us staff used hand gel and washed their hands before making contact.

Staff were aware of the provider’s policies for infection prevention and control and knew how access these. They told us they had received training in infection control, hand hygiene and aseptic non-touch technique. Staff understood the processes managing risks related to the infections. They were able to describe how they cleaned and decontaminated equipment. They understood when people required isolation and how this should be carried out. Staff told us they routinely monitored and escalated any suspected exit wound infections to the managers and medical staff so people could receive appropriate treatment and transfer to hospital if required. Staff told us managers undertook regular infection control and hand hygiene audits. Managers told us shortfalls in hand hygiene or infection control compliance were discussed with individual staff members to improve compliance.

The clinical areas and supporting areas were visibly clean and had suitable furnishings which were clean and well-maintained. Cleaning schedules and daily checklists were in place and up to date, and there were clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment. We observed staff preparing people who use the service prior to dialysis treatment and using aseptic non-touch technique appropriately. We also saw staff cleaned and decontaminated the dialysis equipment appropriately after each use. There were enough hand wash sinks and hand gels. We observed staff following hand hygiene and 'bare below the elbow' guidance appropriately. Service users and visitors were encouraged to wash their hands. All the staff we observed wore suitable personal protective equipment, such as gloves, aprons and visors while delivering care. Clean linen was appropriately stored and segregated in dedicated storage areas. The unit had 6 side rooms, including 2 dedicated isolation rooms which could be used to segregate people with suspected infections.

The service had hygiene and infection control policies which guided staff on processes and practices such as hand hygiene and personal protective equipment, dialysis equipment disinfection. Staff completed competency assessments and mandatory training in infection prevention and control (IPC). Most staff had completed training in IPC, hand hygiene and aseptic non-touch technique. Training completion was above the provider’s target of 90%. The clinic manager was the IPC lead for the service. Senior staff carried out IPC and hand hygiene audits every 3 months. Audit results between March 2024 and August 2024 showed high levels of staff compliance with infection control and hand hygiene standards. Clear guidance available to staff to guide them in deciding when people required isolation and how this should be carried out. People who used the service were routinely screened for known infections. There were procedures to assess and treat carriers of blood borne viruses such as hepatitis B and C. There had been no reportable infection outbreaks at the unit during the past 12 months. The service reported 10 incidents relating exit site infections during the past 12 months. There were no themes or trends and no serious incidents or harm resulting from exit site infections. Records showed people acquiring exit wounds received appropriate treatment and incidents were investigated and learning shared.

People told us staff gave them clear information around medicines and their medicines were prescribed and administered appropriately. People told us they received medicines in a timely manner and did not have any concerns around the storage and handling of medicines.

Staff told us they received training in medicines management and were aware of how to access policies and procedures relating to medicines management. Staff told us they could access timely advice and support from the medical staff and pharmacists at the commissioning trust if they had any concerns around medicines management.

Medicines were stored securely in locked rooms and there was a system for managing access to secured medicines cabinet and room keys. We looked at a sample of medicines and found these were stored securely, reconciled correctly with stock records and were kept within their expiry dates. The service did have use any controlled drugs. Medicines that required storage in fridges had been stored appropriately. Fridge and room temperatures were monitored daily to check the temperature was correct. Emergency oxygen cylinders were stored securely. The service had an arrangement with external provider to replenish oxygen cylinders. We found an FP10 prescription log that showed 2 prescriptions were unaccounted for. The interim clinic manager told us they would look to remove the prescription pads from the service as these belonged to and were used by the renal consultants during outpatient clinics and were not part of the dialysis unit’s routine processes.

The consultants reviewed medicine prescriptions on admission and discussed changes to prescribed medicines as part of monthly multidisciplinary reviews. People were appropriately involved in decisions about their medicines. Medicines management and medicine stock reconciliation audits took place every 3 to 6 months. Recent audit records showed good levels of staff compliance. Actions plans were taken to improve any shortfalls identified and were followed up to check improvements had been made. People’s medicines were appropriately prescribed, supplied and administered in line with the relevant legislation and best practice guidance. Staff completed medicines records accurately and kept them up-to-date. We looked at 5 medicine administration records which were complete and up to date, with few errors or omissions. The service reported 2 incidents relating to medication errors during the past 12 months. These had not resulted in any harm and both incidents had been investigated by staff and action taken to reduce recurrence.