Assure Dialysis Services, Smethwick is operated by Assure Dialysis Services Ltd and has been open since June 2015. The service has 32 active dialysis stations; including eight within individual isolation rooms. However the service has the physical capacity for 40 stations. Facilities include clinic rooms for appointments with staff from the referring trust, meeting rooms and a training area.

The service provides outpatient dialysis treatment for patients over the age of 18 years.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 5 June 2017 along with an unannounced visit to the service on 15 June 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 when they are provided as a single specialty service. 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:

• Staff knew how to report incidents; and were aware of learning following on from incidents. We saw evidence of investigations carried out following the reporting of an incident; and where appropriate concerns were added to the unit’s risk register.

• Staffing was in line with safer staffing requirements. Staff had completed mandatory training, were had been assessed as competent to perform dialysis related procedures and had regular appraisals.

• Data from the unit demonstrated they were producing positive health outcomes for patients following their treatment. The unit monitored adherence to quality standards on a monthly basis in a collaborative way with the referring trust.

• We saw the unit was purpose built and facilities and the building layout were designed to be inclusive of all individuals, including people with additional or different needs.

• Staff were caring, respectful and interested in the lives of the patients whom they treated. We observed staff work in a collaborative way with patients; listening to individual preferences regarding treatment and care.

• Multidisciplinary working was embedded within the unit; we saw a variety of specialist staff, such as a renal psychologist, renal social workers, dietitians and renal consultants offered appointments to patients at the clinic from consulting rooms; therefore making it easier for patients to attend.

• We saw the unit management was supportive and open. Both staff and patients highlighted that the unit manager was approachable and worked actively to manage concerns and problems.

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

• Patients were exposed to risks due to some staff using a technique called 'dry needling' in a non-competent way: (dry needling is using a needle that is not filled with sodium chloride to cannulate the fistula prior to commencing dialysis treatment). We saw that two staff were pushing air into the venous and arterial needle tubing which carried a rare but significant risk of an air embolus entering the blood stream. We raised this at the time of inspection. By the time of the unannounced inspection visit, a competency framework had been developed for staff and we saw staff using this technique were doing so competently.

• We found that 23 out of 40 viable dialysis machines had not been serviced within their due date; despite the maintenance of machinery and equipment being highlighted on the risk register for the unit. This was rectified by the time of the unannounced inspection.

• Infection prevention and control was variable. At times this was very good, with personal protective equipment (PPE) being used, and cleaning done to a high standard. At other times we saw that staff contaminated sterile areas when connecting patients to dialysis machines.

• We saw that staff were not checking patients identification when connecting patients to dialysis machines, or when administering medicine. This was despite warnings on the front of some patients’ files to indicate they had the same name as another patient. We saw that previous medicine errors had been made as a result of this practice, in addition to a patient using a different patient’s dialysis card which was not identified immediately by staff. This was resolved immediately when the wrong card was identified.

• We saw that not all patients were starting their dialysis treatment within 30 minutes of their arrival time; the unit was under their target of 90% within a three month period.

• We saw not all risks on the risk register for the service were monitored to ensure compliance from all parties identified on the action plan; resulting in safety risks to the service.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with one requirement notice(s). Details are at the end of the report.

Heidi Smoult

Deputy Chief Inspector of Hospitals